Recommendations on screening for prostate cancer with the prostate-specific antigen test

Harmonization of clinical practice guidelines for primary prevention and screening: actionable recommendations and resources for primary care

BACKGROUND

Clinical practice guidelines (CPGs) synthesize high-quality information to support evidence-based clinical practice. In primary care, numerous CPGs must be integrated to address the needs of patients with multiple risks and conditions. The BETTER program aims to improve prevention and screening for cancer and chronic disease in primary care by synthesizing CPGs into integrated, actionable recommendations. We describe the process used to harmonize high-quality cancer and chronic disease prevention and screening (CCDPS) CPGs to update the BETTER program.

METHODS

A review of CPG databases, repositories, and grey literature was conducted to identify international and Canadian (national and provincial) CPGs for CCDPS in adults 40-69 years of age across 19 topic areas: cancers, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, hepatitis C, obesity, osteoporosis, depression, and associated risk factors (i.e., diet, physical activity, alcohol, cannabis, drug, tobacco, and vaping/e-cigarette use). CPGs published in English between 2016 and 2021, applicable to adults, and containing CCDPS recommendations were included. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and a three-step process involving patients, health policy, content experts, primary care providers, and researchers was used to identify and synthesize recommendations.

RESULTS

We identified 51 international and Canadian CPGs and 22 guidelines developed by provincial organizations that provided relevant CCDPS recommendations. Clinical recommendations were extracted and reviewed for inclusion using the following criteria: 1) pertinence to primary prevention and screening, 2) relevance to adults ages 40-69, and 3) applicability to diverse primary care settings. Recommendations were synthesized and integrated into the BETTER toolkit alongside resources to support shared decision-making and care paths for the BETTER program.

CONCLUSIONS

Comprehensive care requires the ability to address a person's overall health. An approach to identify high-quality clinical guidance to comprehensively address CCDPS is described. The process used to synthesize and harmonize implementable clinical recommendations may be useful to others wanting to integrate evidence across broad content areas to provide comprehensive care. The BETTER toolkit provides resources that clearly and succinctly present a breadth of clinical evidence that providers can use to assist with implementing CCDPS guidance in primary care.

Analysis of active surveillance uptake for localized prostate cancer in Quebec in 2016: A Canadian bicentric study and comparison with 2010 data

INTRODUCTION

Active surveillance (AS) has emerged as a primary management strategy for low-risk prostate cancer (PC) patients. We aimed to assess AS uptake over a 1-year snapshot throughout Quebec and to compare it to 2010 multicentric Canadian data.

METHODS

A retrospective chart review and data collection was performed in 1 academic and 2 non-academic community centres from Quebec, among men identified in 2016 with localized T1c-T2c PC on biopsy, fulfilling NCCN criteria of low-risk (LR)-PC, including very-low-risk (VLR) and non-VLR-PC, and favourable-intermediate risk (FIR)-PC. AS adherence was defined when chosen as initial strategy, without any radical treatment within 6 months.

RESULTS

Overall, 259 patients fulfilled the inclusion criteria with 50.2% of VLR-PC patients. At 6 months, 81% patients in the LR group and 65% in the FIR group were considered as adherent to AS, in both centres, but with an increased use of AS in the community centres compared to 2010 data. The rates of AS maintenance decreased at 12 months to respectively 69% and 58%. Among the VLR group, the rate of initiation was 98% and decreased to 85% at 12 months.

CONCLUSION

Our data suggest that the majority of low-risk PC patients indeed initiated an AS in 2016, with even a greater proportion of VLR-PC patients compared to 2010. This ideal strategy should be encouraged and improved at 12 months, and assessed with recent data and longer follow-up.

LEVEL OF EVIDENCE: 4

Mucin-producing urothelial-type adenocarcinoma of the prostate with sarcomatoid features and novel molecular phenotype

Introduction

Mucin-producing urothelial-type adenocarcinoma of the prostate is a rare tumor that may not elevate serum prostate-specific antigen, creating significant diagnostic and monitoring challenges. We evaluate our case in detail and review prior studies to demonstrate that the pathologic and molecular features of this tumor are distinct from conventional prostate adenocarcinoma.

Case presentation

Our patient had a remote history of radiation-treated conventional prostate adenocarcinoma and presented many years later with an abscess-like prostate mass leading to urinary obstruction and hematuria. Biopsy revealed mucin-producing urothelial-type adenocarcinoma of the prostate with concurrent sarcomatoid features. Molecular studies showed a unique phenotype involving alterations in the KRAS, PTEN, RAD21, and TP53 genes.

Conclusions

To our knowledge, this is the first report that describes sarcomatoid features and molecular mutations in mucin-producing urothelial-type adenocarcinoma of the prostate.

Cancer incidence during the COVID-19 pandemic by region of residence in Manitoba, Canada: A cancer registry-based interrupted time series study

INTRODUCTION

Health care in Manitoba, Canada is divided into five regions, each with unique geographies, demographics, health care access, and health status. COVID-19-related restrictions and subsequent responses also differed by region. To understand the impact of the pandemic on cancer incidence in the context of these differences, we examined age-standardized cancer incidence rates by region over time before and after the COVID-19 pandemic.

METHODS

We used a population-based quasi-experimental study design, population-based data, and an interrupted time series analysis to examine the rate of new cancer diagnoses before (January 2015 until December 2019) and after the start of COVID-19 and the interventions implemented to mitigate its impact (April 2020 until December 2021) by region.

RESULTS

Overall cancer incidence differed by region and remained lower than expected in Winnipeg (4.6% deficit, 447 cases), Prairie Mountain (6.9% deficit, 125 cases), and Southern (13.0% deficit, 238 cases). Southern was the only region that had a significantly higher deficit in cases compared to Manitoba (ratio 0.92, 95% CI 0.86, 0.99). Breast and colorectal cancer incidence decreased at the start of the pandemic in all regions except Northern. Lung cancer incidence decreased in the Interlake-Eastern region and increased in the Northern region. Prostate cancer incidence increased in Interlake-Eastern.

CONCLUSIONS

The impact of the COVID-19 pandemic on cancer incidence differed by region. The deficit in the number of cases was largest in the southern region and was highest for breast and prostate cancers. Cancer incidence did not significantly decrease in the most northern, remote region.

Health-Related and Psychosocial Factors Associated with Prostate Cancer Stage at Diagnosis among Males Participating in Alberta's Tomorrow Project

Prostate cancer (PCa) stage at diagnosis is an important predictor of cancer prognosis. In Canada, over one-quarter of males are diagnosed with advanced-stage PCa. Studies have identified several factors associated with PCa stage at diagnosis; however, evidence from Canada is limited. This study aimed to examine associations between sociodemographic characteristics, health history, health practices, and psychosocial factors and PCa stage at diagnosis among males participating in Alberta's Tomorrow Project (ATP), a prospective cohort in Alberta, Canada. The study included males aged 35-69 years who developed PCa until January 2018. Factors associated with PCa stage at diagnosis were examined using partial proportional odds (PPO) ordinal regression models. A total of 410 males were diagnosed with PCa over the study period. A higher number of lifetime prostate-specific antigen tests were associated with earlier-stage PCa (OR 0.91, p = 0.02, 95% CI 0.83-0.99), while higher abdominal circumference (OR 1.02, p = 0.05, 95% CI 1.00-1.03), lower social support (OR 2.34, p < 0.01, 95% CI 1.31-4.17), and having children (OR 2.67, p < 0.01, 95% CI 1.38-5.16) were associated with later-stage disease. This study identified factors previously found in the literature as well as novel factors associated with PCa stage at diagnosis, which can help inform targets for cancer prevention programs to improve PCa prognosis.

Genome-wide association study of prostate-specific antigen levels in 392,522 men identifies new loci and improves cross-ancestry prediction

We conducted a multi-ancestry genome-wide association study of prostate-specific antigen (PSA) levels in 296,754 men (211,342 European ancestry; 58,236 African ancestry; 23,546 Hispanic/Latino; 3,630 Asian ancestry; 96.5% of participants were from the Million Veteran Program). We identified 318 independent genome-wide significant (p≤5e-8) variants, 184 of which were novel. Most demonstrated evidence of replication in an independent cohort (n=95,768). Meta-analyzing discovery and replication (n=392,522) identified 447 variants, of which a further 111 were novel. Out-of-sample variance in PSA explained by our new polygenic risk score reached 16.9% (95% CI=16.1%-17.8%) in European ancestry, 9.5% (95% CI=7.0%-12.2%) in African ancestry, 18.6% (95% CI=15.8%-21.4%) in Hispanic/Latino, and 15.3% (95% CI=12.7%-18.1%) in Asian ancestry, and lower for higher age. Our study highlights how including proportionally more participants from underrepresented populations improves genetic prediction of PSA levels, with potential to personalize prostate cancer screening.

New Cancer Diagnoses Before and During the COVID-19 Pandemic

Importance

Disruptions to health care during the COVID-19 pandemic may have led to missed cancer diagnoses. It is critical to evaluate the association between the COVID-19 pandemic and cancer incidence to address public and patient anxiety, inform recovery efforts, and identify strategies to reduce the system's vulnerability to future disruptions.

Objective

To examine the association between the COVID-19 pandemic and cancer incidence in Manitoba, Canada.

Design, Setting, and Participants

A population-based cross-sectional study design was conducted using data from the Manitoba Cancer Registry and an interrupted time-series analysis. All individuals diagnosed with cancer in Manitoba, Canada, from January 1, 2015, until December 31, 2021, were included. Individuals diagnosed with breast, colon, rectal, or lung cancer were grouped by age as follows: younger than 50 years, 50 to 74 years, and 75 years and older.

Exposures

COVID-19 pandemic.

Main Outcomes and Measures

Age-standardized cancer incidence rates and the estimated cumulative difference between the number of cases in the absence of COVID-19 and observed (fitted) number of cancer cases.

Results

A total of 48 378 individuals were included. The median (IQR) age at diagnosis was 68 (59-77) years and 23 972 participants (49.6%) were female. In April 2020, there was a 23% decrease in overall cancer incidence. Cancer incidence decreased by 46% for breast, 35% for colon, 47% for rectal, 50% for head and neck, 65% for melanoma, and 33% for endocrine cancer diagnoses and increased by 12% for hematological cancer diagnoses and 8% for diagnoses of cancers with an unknown primary site. Lung cancer incidence remained stable until December 2020 when it decreased by 11%. Brain and central nervous system and urinary cancer diagnoses decreased consistently over time from April 2020 to December 2021 by 26% and 12%, respectively. No association was observed with gynecologic (1% increase), other digestive (1% decrease), or pancreatic (7% increase) cancer incidence. As of December 2021, Manitoba had an estimated deficit of 692 (5.3%) cancers. The largest estimated deficits were for breast (273 cases, 14.1% deficit), colon (133 cases, 12.2% deficit), and lung cancers (132 cases, 7.6% deficit).

Conclusions and Relevance

In this study, the COVID-19 pandemic was associated with an initial decrease in cancer diagnosis incidence followed by a recovery for most cancer sites. However, the cumulative deficit for some cancers with high fatality needs immediate attention.

Clinical analysis of EV-Fingerprint to predict grade group 3 and above prostate cancer and avoid prostate biopsy

BACKGROUND

There is an unmet clinical need for minimally invasive diagnostic tests to improve the detection of grade group (GG) ≥3 prostate cancer relative to prostate antigen-specific risk calculators. We determined the accuracy of the blood-based extracellular vesicle (EV) biomarker assay (EV Fingerprint test) at the point of a prostate biopsy decision to predict GG ≥3 from GG ≤2 and avoid unnecessary biopsies.

METHODS

This study analyzed 415 men referred to urology clinics and scheduled for a prostate biopsy, were recruited to the APCaRI 01 prospective cohort study. The EV machine learning analysis platform was used to generate predictive EV models from microflow data. Logistic regression was then used to analyze the combined EV models and patient clinical data and generate the patients' risk score for GG ≥3 prostate cancer.

RESULTS

The EV-Fingerprint test was evaluated using the area under the curve (AUC) in discrimination of GG ≥3 from GG ≤2 and benign disease on initial biopsy. EV-Fingerprint identified GG ≥3 cancer patients with high accuracy (0.81 AUC) at 95% sensitivity and 97% negative predictive value. Using a 7.85% probability cutoff, 95% of men with GG ≥3 would have been recommended a biopsy while avoiding 144 unnecessary biopsies (35%) and missing four GG ≥3 cancers (5%). Conversely, a 5% cutoff would have avoided 31 unnecessary biopsies (7%), missing no GG ≥3 cancers (0%).

CONCLUSIONS

EV-Fingerprint accurately predicted GG ≥3 prostate cancer and would have significantly reduced unnecessary prostate biopsies.

Dissemination and implementation of clinical practice guidelines: a longitudinal, mixed-methods evaluation of the Canadian Task Force on Preventive Health Care's knowledge translation efforts

BACKGROUND

The Canadian Task Force on Preventive Health Care (task force) develops evidence-based preventive health care guidelines and knowledge translation (KT) tools to facilitate guideline dissemination and implementation. We aimed to determine practitioners' awareness of task force guidelines and KT tools and explore barriers and facilitators to their use.

METHODS

The task force's KT team completed annual evaluations using surveys and interviews with primary care providers in Canada from 2014 to 2020, to assess practitioners' awareness and determinants of use of task force guidelines and tools. We transcribed interviews verbatim and double-coded them using a framework analysis approach.

RESULTS

A total of 1284 primary care practitioners completed surveys and 183 participated in interviews. On average, 79.9% of participants were aware of the task force's 7 cancer screening guidelines, 36.2% were aware of the other 6 screening guidelines and 18.6% were aware of the 3 lifestyle or prevention guidelines. Participants identified 13 barriers and 7 facilitators to guideline and KT tool implementation; these were consistent over time. Participants identified strategies at the public and patient, provider and health systems levels to improve uptake of guidelines.

INTERPRETATION

Canadian primary care practitioners were more aware of task force cancer screening guidelines than its other preventive health guidelines. Over the 6-year period, participants consistently reported barriers to guideline uptake, including misalignment with patient preferences and other provincial or specialty guideline organizations. Further evaluations will assess tailored strategies to address the barriers identified.

Protocol of a multicentre randomised controlled trial assessing transperineal prostate biopsy to reduce infectiouscomplications

INTRODUCTION

Approximately one million prostate biopsies are performed annually in the USA, and most are performed using a transrectal approach under local anaesthesia. The risk of postbiopsy infection is increasing due to increasing antibiotic resistance of rectal flora. Single-centre studies suggest that a clean, percutaneous transperineal approach to prostate biopsy may have a lower risk of infection. To date, there is no high-level evidence comparing transperineal versus transrectal prostate biopsy. We hypothesise that transperineal versus transrectal prostate biopsy under local anaesthesia has a significantly lower risk of infection, similar pain/discomfort levels and comparable detection of non-low-grade prostate cancer.

METHODS AND ANALYSIS

We will perform a multicentre, prospective randomised clinical trial to compare transperineal versus transrectal prostate biopsy for elevated prostate-specific antigen in the first biopsy, prior negative biopsy and active surveillance biopsy setting. Prostate MRI will be performed prior to biopsy, and targeted biopsy will be conducted for suspicious MRI lesions in addition to systematic biopsy (12 cores). Approximately 1700 men will be recruited and randomised in a 1:1 ratio to transperineal versus transrectal biopsy. A streamlined design to collect data and to determine trial eligibility along with the two-stage consent process will be used to facilitate subject recruitment and retention. The primary outcome is postbiopsy infection, and secondary outcomes include other adverse events (bleeding, urinary retention), pain/discomfort/anxiety and critically, detection of non-low-grade (grade group ≥2) prostate cancer.

ETHICS AND DISSEMINATION

The Institutional Review Board of the Biomedical Research Alliance of New York approved the research protocol (protocol number #18-02-365, approved 20 April 2020). The results of the trial will be presented at scientific conferences and published in peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

NCT04815876.

Associations of Content and Context of Communication with Prostate-Specific Antigen Testing

There is limited research about the content and context of communication on prostate-specific antigen (PSA) testing among men in the state of Florida. The purpose of this study is to understand how the content communication (discussion of advantages and disadvantages of PSA testing between provider and patient; provider recommendations of PSA testing) and the context of communication (continuity of care denoted by the presence of a personal doctor) influence PSA testing. Data were drawn from the Florida Behavioral Risk Factor Surveillance System. Receipt of PSA testing was the primary outcome. Multiple logistic regression analyses were used to adjust for sociodemographic, clinical, healthcare access, and lifestyle characteristics when associating the content and context of communication with PSA testing. Discussions were classified into four mutually exclusive categories: discussions of advantages and disadvantages, only advantages, only disadvantages, and no discussion. The most significant predictors for PSA testing included physician recommendation, discussions including advantages, older age, non-smoking, and having a personal doctor. Individualized PSA screening may be a pathway to reducing racial disparities in screening for prostate cancer (PCa) and, by extension, lower incidence and mortality rates. Developing a bill to create an Office of Men's Health at Health & Human Services is recommended.

Strategies used in managing conversations about prostate-specific antigen (PSA) testing among family physicians (FPs): a qualitative study

OBJECTIVES

Screening for prostate cancer in healthy asymptomatic men using the prostate-specific antigen (PSA) test is controversial due to conflicting recommendations from and a lack of strong evidence regarding the benefit of population-based screening. In Canada and internationally, there is variability in how family physicians (FPs) approach PSA testing in asymptomatic men. The purpose of our study was to explore how family FPs approach discussions with their male patients around PSA testing in Manitoba, Canada.

DESIGN

Qualitative descriptive study.

SETTING AND PARTICIPANTS

High-ordering and median-ordering FPs were invited to participate in an interview. In addition to exploring practice behaviours around PSA testing, participants were asked to elaborate on their typical discussion with asymptomatic men who request a PSA test or other tests and procedures that they do not feel are clinically warranted. Data were analysed inductively using a constant-comparison approach.

RESULTS

There were important variations between high-ordering and median-ordering FP's approaches to discussing PSA testing. Strategies to facilitate conversations were more frequently identified by median-ordering physicians and often included methods to facilitate assessing their patient's understanding and values. In addition to decision aids, median-ordering FPs used motivational interviewing to tailor a discussion, organised their practice structure and workflow habits in a way that enhanced patient-provider discussions and leveraged 'new' evidence and other aids to guide conversations with men.

CONCLUSION

We found that high-ordering FPs tended to use the PSA test for screening asymptomatic men with limited shared decision-making. Median-ordering FPs used conversational strategies that emphasised uncertainty of benefit and potential risk and did not present the test as a recommendation.

Spatial patterns of prostate-specific antigen testing in asymptomatic men across Australia: a population-based cohort study, 2017-2018

OBJECTIVES

In Australia, while prostate-specific antigen (PSA) testing rates vary by broad area-based categories of remoteness and socio-economic status, little is known about the extent of variation within them. This study aims to describe the small-area variation in PSA testing across Australia.

STUDY DESIGN

This was a retrospective population-based cohort study.

METHODS

We received data for PSA testing from the Australian Medicare Benefits Schedule. The cohort included men (n = 925,079) aged 50-79 years who had at least one PSA test during 2017-2018. A probability-based concordance was applied across multiple iterations (n = 50) to map each postcode to small areas (Statistical Areas 2; n = 2,129). For each iteration, a Bayesian spatial Leroux model was used to generate smoothed indirectly standardized incidence ratios across each small area, with estimates combined using model averaging.

RESULTS

About a quarter (26%) of the male population aged 50-79 years had a PSA test during 2017-2018. Testing rates among small areas varied 20-fold. Rates were higher (exceedance probability>0.8) compared with the Australian average in the majority of small areas in southern Victoria and South Australia, south-west Queensland, and some coastal regions of Western Australia but lower (exceedance probability<0.2) in Tasmania and Northern Territory.

CONCLUSIONS

The substantial geographical variation in PSA testing rates across small areas of Australia may be influenced by differences in access to and guidance provided by clinicians and attitudes and preferences of men. Greater understanding of PSA testing patterns by subregions and how these patterns relate to health outcomes could inform evidence-based approaches to identifying and managing prostate cancer risk.

Building predictive disease models using extracellular vesicle microscale flow cytometry and machine learning

Extracellular vesicles (EVs) are highly abundant in human biofluids, containing a repertoire of macromolecules and biomarkers representative of the tissue of origin. EVs released by tumours can communicate key signals both locally and to distant sites to promote growth and survival or impact invasive and metastatic progression. Microscale flow cytometry of circulating EVs is an emerging technology that is a promising alternative to biopsy for disease diagnosis. However, biofluid-derived EVs are highly heterogeneous in size and composition, making their analysis complex. To address this, we developed a machine learning approach combined with EV microscale cytometry using tissue- and disease-specific biomarkers to generate predictive models. We demonstrate the utility of this novel extracellular vesicle machine learning analysis platform (EVMAP) to predict disease from patient samples by developing a blood test to identify high-grade prostate cancer and validate its performance in a prospective 215 patient cohort. Models generated using the EVMAP approach significantly improved the prediction of high-risk prostate cancer, highlighting the clinical utility of this diagnostic platform for improved cancer prediction from a blood test.

Hospital-based prostate cancer screening in vietnamese men with lower urinary tract symptoms: a classification and regression tree model

BACKGROUND

Prostate cancer (PCa) is a common disease in men over 65 years of age, and should be detected early, while reducing unnecessary biopsies. This study aims to construct a classification and regression tree (CART) model (i.e., risk stratification algorithm) using multivariable approach to select Vietnamese men with lower urinary tract symptoms (LUTS) for PCa biopsy.

METHODS

We conducted a case-control study on 260 men aged ≥ 50 years who visited MEDIC Medical Center, Vietnam in 2017-2018 with self-reported LUTS. The case group included patients with a positive biopsy and the control group included patients with a negative biopsy diagnosis of PCa. Bayesian Model Averaging (BMA) was used for selecting the most parsimonious prediction model. Then the CART with 5-fold cross-validation was constructed for selecting men who can benefit from PCa biopsy in steps by steps and intuitive way.

RESULTS

BMA suggested five potential prediction models, in which the most parsimonious model including PSA, I-PSS, and age. CART advised the following cut-off points in the marked screening sequence: 18 < PSA < 33.5 ng/mL, I-PSS ≥ 19, and age ≥ 71. Patients with PSA ≥ 33.5 ng/mL have a PCa risk was 91.2%; patients with PSA < 18 ng/mL and I-PSS < 19 have a PCa risk was 7.1%. Patient with 18 ≤ PSA < 33.5ng/mL and I-PSS < 19 have a PCa risk is 70% if age ≥ 71; and is 16% if age < 71. In overall, CART reached high predictive value with AUC = 0.915. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CART at the 20% diagnosis probability threshold were 91.5%, 86.2%, 86.9%, 91.2%, and 88.9% respectively; at 80% diagnosis probability threshold were 79.2%, 92.3%, 91.2%, 81.6%, and 85.8% respectively.

CONCLUSION

CART combining PSA, I-PSS, and age has practical use in hospital-based PCa screening in Vietnamese men with lower urinary tract symptoms.

Screening for prostate cancer: protocol for updating multiple systematic reviews to inform a Canadian Task Force on Preventive Health Care guideline update

PURPOSE

To inform updated recommendations by the Canadian Task Force on Preventive Health Care on screening for prostate cancer in adults aged 18 years and older in primary care. This protocol outlines the planned scope and methods for a series of systematic reviews.

METHODS

Updates of two systematic reviews and a de novo review will be conducted to synthesize the evidence on the benefits and harms of screening for prostate cancer with a prostate-specific antigen (PSA) and/or digital rectal examination (DRE) (with or without additional information) and patient values and preferences. Outcomes for the benefits of screening include reduced prostate cancer mortality, all-cause mortality, and incidence of metastatic prostate cancer. Outcomes for the harms of screening include false-positive screening tests, overdiagnosis, complications due to biopsy, and complications of treatment including incontinence (urinary or bowel), and erectile dysfunction. The quality of life or functioning (overall and disease-specific) and psychological effects outcomes are considered as a possible benefit or harm. Outcomes for the values and preferences review include quantitative or qualitative information regarding the choice to screen or intention to undergo screening. For the reviews on benefits or harms, we will search for randomized controlled trials, quasi-randomized, and controlled studies in MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. For the review on values and preferences, we will search for experimental or observational studies in MEDLINE, Embase, and PsycInfo. For all reviews, we will also search websites of relevant organizations, gray literature, and reference lists of included studies. Title and abstract screening, full-text review, data extraction, and risk of bias assessments will be completed independently by pairs of reviewers with any disagreements resolved by consensus or by consulting with a third reviewer. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach will be used to assess the certainty of the evidence for each outcome.

DISCUSSION

The series of systematic reviews will be used by the Canadian Task Force on Preventive Health Care to update their 2014 guideline on screening for prostate cancer in adults aged 18 years and older. Systematic review registration This review has been registered with PROSPERO (CRD42022314407) and is available on the Open Science Framework (osf.io/dm32k).

Novel sensitive immunosensor for the selective detection of Engrailed 2 urinary prostate cancer biomarker

Engrailed 2 (EN2) is a homeodomain-containing transcription factor expressed in prostate cancer (PCa) cell lines and is secreted into the urines. It is nowadays considered as a promising non-invasive biomarker for PCa early diagnosis. Herein, we report the design of an electrochemical immunosensor for EN2 detection. The biosensor fabrication involved a covalent immobilization of anti-EN2 antibodies onto a poly para amino benzoic acid (PABA) film electropolymerized on a gold electrode. Square wave voltammetry was investigated for EN2 detection in a phosphate buffer solution in a concentration range of 10^-5 ng/mL to 1 μg/mL. The limit of detection of the designed sensor was equal to 10^-5 ng/mL and the sensitivity was of order of (29 ± 2) μL/ng. The dissociation constant K_d of the "complex" EN2/anti-EN2, estimated from a Hill model, was of order of (0.9 ± 0.2) fM. Experimental results revealed that the immunosensor enabled selective detection of EN2 in a mixture of three proteins which can be found in men' urine: human serum albumin (HSA), prostate-specific antigen (PSA) and immunoglobulin G (IgG). Tests in artificial urine, with an ionic strength of 0.18 M, have been done and results were found comparable to those obtained in PBS (0.16 M). These encouraging results show a potentially promising future for the development of an electrochemical biosensor for robust and accurate urinary biomarkers detection.

Inherited risk assessment and its clinical utility for predicting prostate cancer from diagnostic prostate biopsies

BACKGROUND

Many studies on prostate cancer (PCa) germline variants have been published in the last 15 years. This review critically assesses their clinical validity and explores their utility in prediction of PCa detection rates from prostate biopsy.

METHODS

An integrative review was performed to (1) critically synthesize findings on PCa germline studies from published papers since 2016, including risk-associated single nucleotide polymorphisms (SNPs), polygenic risk score methods such as genetic risk score (GRS), and rare pathogenic mutations (RPMs); (2) exemplify the findings in a large population-based cohort from the UK Biobank (UKB); (3) identify gaps for implementing inherited risk assessment in clinic based on experience from a healthcare system; (4) evaluate available GRS data on their clinical utility in predicting PCa detection rates from prostate biopsies; and (5) describe a prospective germline-based biopsy trial to address existing gaps.

RESULTS

SNP-based GRS and RPMs in four genes (HOXB13, BRCA2, ATM, and CHEK2) were significantly and consistently associated with PCa risk in large well-designed studies. In the UKB, positive family history, RPMs in the four implicated genes, and a high GRS (>1.5) identified 8.12%, 1.61%, and 17.38% of men to be at elevated PCa risk, respectively, with hazard ratios of 1.84, 2.74, and 2.39, respectively. Additionally, the performance of GRS for predicting PCa detection rate on prostate biopsy was consistently supported in several retrospective analyses of transrectal ultrasound (TRUS)-biopsy cohorts. Prospective studies evaluating the performance of all three inherited measures in predicting PCa detection rate from contemporary multiparametric MRI (mpMRI)-based biopsy are lacking. A multicenter germline-based biopsy trial to address these gaps is warranted.

CONCLUSIONS

The complementary performance of three inherited risk measures in PCa risk stratification is consistently supported. Their clinical utility in predicting PCa detection rate, if confirmed in prospective clinical trials, may improve current decision-making for prostate biopsy.

Brazilian Survey on Preventive Actions for the Population With Access to Primary Healthcare: Inefficient Spending in a Country in Economic Crisis

BACKGROUND

Cancer ranks second as a cause of death in Brazil. Although preventive practices are part of the daily routine of primary healthcare (PHC) teams, organized screening programs are lacking. This study aimed to evaluate the adequacy of preventive interventions in the main cancer types, as defined by the Brazilian government.

METHODS

We analyzed cross-sectional data from a larger project conducted in 2016 with PHC service users and physicians from all over Brazil, interviewed by trained research staff. The sample was stratified by the number of PHC physicians per geographic region, who were eligible for inclusion if they had been working in the same PHC unit for at least one year. Twelve adult patients with at least two encounters were included per participating physician. Only the data from service users were analyzed in this study. We evaluated the questions about preventive practices and calculated the following indicators: coverage, focus, screening errors, and screening ratio. National guidelines and international evidence were used as a comparison parameter.

RESULTS

The study population consisted of 6160 service users. The data indicate that the recommendations for cervical, breast, and prostate cancer screening and for treatment of tobacco dependence are not adequately followed. Coverage for breast and cervical cancer screening presented an overutilization bias, with rates 50% and 9% above the expected, respectively. The screening focus was also inadequate: 24%, 47%, and 54% of the screening tests for the three cancer types were performed in individuals outside the recommended age range. 31% of smokers were not approached for treatment.

CONCLUSION

These findings indicate that the Brazilian population has been subjected to inadequate and potentially iatrogenic interventions in PHC. New policies based on stricter criteria of adequacy and increased use of the concept of quaternary prevention may improve the effectiveness and equity of the health system.

Cancer risk among firefighters and police in the Ontario workforce

OBJECTIVE

Firefighters and police often work in high-stress, complex environments with known and suspected carcinogenic exposures. We aimed to characterise cancer incidence among firefighters and police.

METHODS

The Occupational Disease Surveillance System (ODSS) was used to identify workers employed as firefighters or police in Ontario. A cohort of workers were identified using lost-time workers' compensation claims data and followed for cancer in the Ontario Cancer Registry (1983-2020). Cox proportional hazard models were used to estimate HRs and 95% CIs for primary site-specific cancer diagnoses adjusted for age at start of follow-up, birth year and sex.

RESULTS

A total of 13 642 firefighters and 22 595 police were identified in the cohort. Compared with all other workers in the ODSS, firefighters and police had increased risk of prostate cancer (firefighters: HR=1.43, 95% CI 1.31 to 1.57; police: HR=1.47, 95% CI 1.35 to 1.59), colon cancer (firefighters: HR=1.39, 95% CI 1.19 to 1.63; police: HR=1.39, 95% CI 1.21 to 1.60) and skin melanoma (firefighters: HR=2.38, 95% CI 1.99 to 2.84; police: HR=2.27, 95% CI 1.96 to 2.62). Firefighters also had increased risk of cancer of the pancreas, testis and kidney, as well as non-Hodgkin's lymphoma and leukaemia. Police had increased risk of thyroid, bladder and female breast cancer. When compared directly with the police, firefighters had an elevated risk of mesothelioma and testicular cancer.

CONCLUSIONS

Firefighters and police demonstrated some similar as well as some unique cancer risks. Findings from this larger worker population may have important implications for workplace and policy-level changes to improve preventative measures and reduce potential exposures to known carcinogenic hazards.

Molecular mechanisms and clinical applications of exosomes in prostate cancer

Prostate cancer (PC) is a common tumor in men, and the incidence rate is high worldwide. Exosomes are nanosized vesicles released by all types of cells into multiple biological fluid types. These vesicles contribute to intercellular communication by delivering both nucleic acids and proteins to recipient cells. In recent years, many studies have explored the mechanisms by which exosomes mediate the epithelial-mesenchymal transition, angiogenesis, tumor microenvironment establishment, and drug resistance acquisition in PC, and the mechanisms that have been identified and the molecules involved have provided new perspectives for the possible discovery of novel diagnostic markers in PC. Furthermore, the excellent biophysical properties of exosomes, such as their high stability, high biocompatibility and ability to cross biological barriers, have made exosomes promising candidates for use in novel targeted drug delivery system development. In this review, we summarize the roles of exosomes in the growth and signal transmission in PC and show the promising future of exosome contributions to PC diagnostics and treatment.

Update on cancer incidence trends in Canada, 1984 to 2017

This paper highlights findings on cancer trends from the Canadian Cancer Statistics 2021 report. Trends were measured using annual percent change (APC) of age-standardized incidence rates. Overall, cancer incidence rates are declining (-1.1%) but the findings are specific to the type of cancer and patient sex. For example, in males, the largest decreases per year were for prostate (-4.4%), colorectal (-4.3%), lung (-3.8%), leukemia (-2.6%) and thyroid (-2.4%) cancers. In females, the largest decreases were for thyroid (-5.4%), colorectal (-3.4%) and ovarian (-3.1%) cancers.

Projected estimates of cancer in Canada in 2022

BACKGROUND

Regular cancer surveillance is crucial for understanding where progress is being made and where more must be done. We sought to provide an overview of the expected burden of cancer in Canada in 2022.

METHODS

We obtained data on new cancer incidence from the National Cancer Incidence Reporting System (1984-1991) and Canadian Cancer Registry (1992-2018). Mortality data (1984-2019) were obtained from the Canadian Vital Statistics - Death Database. We projected cancer incidence and mortality counts and rates to 2022 for 22 cancer types by sex and province or territory. Rates were age standardized to the 2011 Canadian standard population.

RESULTS

An estimated 233 900 new cancer cases and 85 100 cancer deaths are expected in Canada in 2022. We expect the most commonly diagnosed cancers to be lung overall (30 000), breast in females (28 600) and prostate in males (24 600). We also expect lung cancer to be the leading cause of cancer death, accounting for 24.3% of all cancer deaths, followed by colorectal (11.0%), pancreatic (6.7%) and breast cancers (6.5%). Incidence and mortality rates are generally expected to be higher in the eastern provinces of Canada than the western provinces.

INTERPRETATION

Although overall cancer rates are declining, the number of cases and deaths continues to climb, owing to population growth and the aging population. The projected high burden of lung cancer indicates a need for increased tobacco control and improvements in early detection and treatment. Success in breast and colorectal cancer screening and treatment likely account for the continued decline in their burden. The limited progress in early detection and new treatments for pancreatic cancer explains why it is expected to be the third leading cause of cancer death in Canada.

Predictive value of PSA density in the diagnosis of prostate cancer in lebanese men

OBJECTIVE

Being the second most common cancer in men, prostate cancer detection relies on laboratory tests, imaging, and surgical procedures, although biopsy remains the mainstay in diagnosis of prostate cancer. No clear cut-off of prostate specific antigen density (PSAD) for suspecting prostate cancer has been established in the Lebanese population. Our primary objective was to evaluate the diagnostic strength of the PSAD value versus total prostate specific antigen (tPSA) level in the Lebanese men in correlation with biopsy outcome to avoid unnecessary prostate biopsy.

METHODS

A retrospective study of 347 patients with history of prostate biopsy done for cancer suspicion included tPSA, prostate volume, and prostate density values and results of prostate biopsy. Data was collected from Bahman hospital and statistical analysis of the mean values of tPSA, prostate volume and PSAD in different age groups was done. Significance of the results was tested using.

RESULTS

On average, patients with negative biopsies were younger and they had lower tPSA levels, lower PSAD values and larger prostate volume compared to patients with positive biopsies. A PSAD cutoff of 0.185 ng/ml2 revealed the highest predictive strength for prostate cancer (6 times risk) compared with other parameters. These findings were mainly referred to patients with PSA > 10 ng/ml.

CONCLUSIONS

A multifactorial approach must be conducted including all parameters in order to decide upon the need for prostate biopsy. PSAD proved to be a good marker in favor or against a prostate biopsy with a cut-off of 0.185 ng/ml2, especially in patients with tPSA level higher to 10 ng/ml. A multicenter study was recommended for better and more reliable results and more precise cut-offs.

Shared decision-making in urology and female pelvic floor medicine and reconstructive surgery

Shared decision-making (SDM) is a hallmark of patient-centred care that uses informed consent to help guide patients with making complex health-care decisions. In SDM, patients and providers work together to determine the best course of action based on both the current available evidence and the patient's values and preferences. SDM not only provides a framework for the legal and ethical obligations providers need to fulfil for informed consent, but also leads to improved knowledge of treatment options and satisfaction of decision-making for patients. Tools such as decision aids have been developed to support SDM for complex decisions. Several decision aids are available for use in the field of urology and female pelvic medicine and reconstructive surgery, but these decision aids are also associated with barriers to SDM implementation including patient, provider and systematic challenges. However, solutions to such barriers to SDM include continued development of SDM tools to improve patient engagement, expand training of providers in SDM communication models and a process to encourage implementation of SDM.

Prostate Cancer Incidence and Mortality: Global Status and Temporal Trends in 89 Countries From 2000 to 2019

Aims

To evaluate current status of prostate cancer incidence and mortality worldwide, and compare the global trends of incidence and mortality in the past two decades and in the most recent period.

Methods

Data on the incidence and mortality of prostate cancer for 174 countries in 2020 were obtained from the GLOBOCAN 2020 database, and associations with the human development index (HDI) were evaluated. Data for trend analyses in 89 countries from 2000 to 2019 were retrieved from the Global Burden of Disease 2019 platform. Age standardized incidence rate (ASIR) and mortality rate (ASMR) were calculated by using the Segi's population. The average annual percent changes (AAPC) of ASIRs and ASMRs were evaluated by joinpoint regression analysis.

Results

A total of 1 414 259 new cases of prostate cancer and 375 304 related deaths were reported in 2020 globally. HDI was positively correlated with ASIRs (P &lt; 0.001) and negatively correlated with ASMRs (P &lt; 0.001). In the past two decades, ASIRs have been increasing in 65 countries, stable in 15 countries and decreasing in 9 countries, and ASMRs have been increasing in 19 countries, stable in 25 countries and decreasing in 45 countries, respectively. In the most recent period, 44 countries have increasing ASIRs, and 32 countries have decreasing ASMRs, respectively. For instance, in the United States of America, the AAPC of ASIRs significantly decreased by 0.62% and ASMRs significantly decreased by 1.22% from 2000 to 2019, while the AAPC from 2015 to 2019 significantly increased by 0.49% for ASIRs and significantly increased by 0.48% for ASMRs.

Conclusion

The magnitude of increasing incidence and decreasing mortality of prostate cancer is attenuated in the recent period. Further study is needed to analyze the absolute effect of risk factors, PSA screening and treatment.

Insufficient Lycopene Intake Is Associated With High Risk of Prostate Cancer: A Cross-Sectional Study From the National Health and Nutrition Examination Survey (2003-2010)

Although lycopene intake and risk of prostate cancer have been explored for decades, recent studies show that Non-Hispanic Black Prostate Cancer (PCa) patients benefit less than Non-Hispanic White patients from a lycopene intake intervention program. This study examined whether a lycopene intake-related racial disparity exists in reducing the risk of PCa in healthy adults. Data on healthy, cancer-free Non-Hispanic Black (NHB) men (n = 159) and Non-Hispanic White (NHW) men (n = 478) from the 2003 to 2010 NHANES dataset were analyzed. Total lycopene intake from daily diet, age, living status, race/ethnicity, education level, poverty income ratio, body mass index, and smoking status were studied as independent variables. The combination of total Prostate-Specific Antigen (PSA) level and the ratio of free PSA was set as criteria for evaluating the risk of PCa. Multivariable logistic regression was used in race-stratified analyses to compute odds ratios (OR) and 95% confidence intervals (95% CI) comparing high PCa risk with low PCa risk. We found, in the whole population, race/ethnicity was the only factor that influenced lycopene intake from the daily diet. NHB men consumed less lycopene than NHW men (3,716 vs. 6,487 (mcg), p = 0.01). Sufficient lycopene intake could reduce the risk of PCa (OR: 0.40, 95% CI: 0.18-0.85, p = 0.02). Men aged between 66 and 70 had high PCa risk (OR: 3.32, 95% CI: 1.12-9.85, p = 0.03). Obesity served as a protective factor against the high risk of PCa (OR: 0.25, 95% CI: 0.12-0.54, p = 0.001). NHW men aged between 66 and 70 had a high risk of PCa (OR: 4.01, 95% CI: 1.02-15.73, p = 0.05). Obese NHW men also had lower risk of PCa (OR: 0.18, 95% CI: 0.07-0.47 p = 0.001). NHB men had a high risk of PCa compared to NHW men (OR: 2.27, 95% CI: 1.35-3.81 p = 0.004). NHB men who were living without partners experienced an even higher risk of PCa (OR: 3.35, 95% CI: 1.01-11.19 p = 0.07). Sufficient lycopene intake from daily food could serve as a protector against PCa. Such an association was only observed in NHW men. Further studies are needed to explore the dose-response relationship between lycopene intake and the association of PCa risk in NHB men.

An origami paper-based peptide nucleic acid device coupled with label-free DNAzyme probe hybridization chain reaction for prostate cancer molecular screening test

Prostate cancer associated 3 (PCA3) assay has been used to improve prostate cancer diagnosis and reduce unnecessary biopsies. In this work, we successfully developed a new PCA3 assay on an origami paper-based peptide nucleic acid device (oPAD). The PCA3 oPAD comprises an acrylic cassette and shutter slides to facilitate the molecular reaction and liquid control occurring on the paper surface. To quantify PCA3, a pyrrolidinyl peptide nucleic acid (acpcPNA) was immobilized onto the aldehyde-modified oPAD surface as a selective capture probe. A G-quadruplex (GQD) DNAzyme reporter probe was designed so that the PCA3 gene target binding triggered the hybridization chain reaction of the reporter probe, resulting in the accumulation of the GQD on the oPAD. The peroxidase activity of the GQD-hemin generated a deep green color of the oxidized ABTS substrate. Image analyses were performed in Adobe Photoshop CS6. The proposed oPAD was successfully applied in PCA3 detection ranges of 1-5 μM (r² = 0.982) with a limit of detection of 0.5 μM. Our proposed oPAD was demonstrated to measure PCA3 samples in both urine matrix and human cancer cell lines. The results reveal the great potential of our origami paper-based platform to be an alternative approach for facile, rapid, and low-cost detection of PCA3 in real samples.

Prostate Cancer in Lebanon: Incidence, Temporal Trends, and Comparison to Countries From Different Regions in the World

BACKGROUND

Prostate cancer is the most common malignancy in men globally. This study aims at investigating the incidence rates and trends of prostate cancer in Lebanon, and to compare them to those of countries from different regions in the world.

METHODS

Data on prostate cancer were obtained from the Lebanese national cancer registry for the years 2005 to 2016. The calculated age-standardized incidence and age-specific rates were expressed as per 100 000 population.

RESULTS

In Lebanon, prostate cancer is ranked as the most common cancer in men. The age-standardized incidence rate of prostate cancer has increased from 29.1 per 100 000 in 2005 to 37.3 per 100 000 in 2016; the highest rate was in 2012, surpassing the global average incidence rate for that year. The age-specific incidence rate of prostate cancer has increased exponentially starting at the age of 50 years to reach its peak in men aged 75 years or more. Two trends were identified in the age-standardized incidence rate of prostate cancer; an average significant increase of 7.28% per year for the period 2005-2009 (P-value < .05), followed by a non-significant decrease of around .99% for the period between 2009 and 2016 (P-value > .05). The age-standardized incidence rate in Lebanon was higher than most countries in the Middle East and North Africa region and Asia, but lower than the rates reported in Australia, America, and different European countries.

CONCLUSION

Prostate cancer is the leading cancer among men in Lebanon. Screening practices, changes in population age structure, and prevalence of genetic and risky lifestyle factors may explain the increased incidence rates of prostate cancer. Given the controversy of screening recommendations and the slow growing nature of prostate cancer, increasing public awareness on ways of prevention, and implementing the latest screening recommendation of the United States Preventive Services Task Force are the suggested way forward.

THE ROLE OF HEALTH LITERACY IN PROSTATE CANCER SCREENING

OBJECTIVE

To determine if there is an association between self-reported health literacy and rates of prostate cancer screening through PSA testing.

METHODS

This secondary data analysis utilized information from the 2016 Behavioral Risk Factor Surveillance System (BRFSS). The primary exposure was self-reported health literacy, and the primary outcome was whether patients underwent prior PSA testing. Males 55-69 years old from 13 states were included in the study and were excluded if they had any missing data. Participants were categorized into low, moderate, or high level of health literacy. Confounders were adjusted for using binary logistic regression. Odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

A total of 12,149 participants were included. Five percent of participants reported low health literacy, 54% moderate health literacy, and 41% high health literacy. Compared with study participants who self-reported high levels of health literacy, the odds of undergoing PSA testing were 59% lower in those with low health literacy (OR 0.41; 95% CI 0.28-0.64) and 30% lower in those with moderate health literacy (OR 0.70; 95% CI 0.60-0.83).

CONCLUSIONS

Our research demonstrates a positive association between self-reported health literacy and the likelihood of PSA screening. While PSA screening can be controversial, health literacy may serve as a window into which patients are more likely to be proactive in their urologic care. Future studies examining how health literacy effects other urologic conditions is necessary.

Assessment of prostate-specific antigen screening: an evidence-based report by the German Institute for Quality and Efficiency in Health Care

CONTEXT

Prostate-specific antigen (PSA) testing increases prostate cancer diagnoses and reduces long-term disease-specific mortality, but also results in overdiagnoses and treatment-related harms.

OBJECTIVE

To systematically assess the benefits and harms of population-based PSA screening and the potential net benefit to inform health policy decision-makers in Germany.

EVIDENCE ACQUISITION

We performed a protocol-guided comprehensive literature search according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. All steps were performed by one or two investigators; any discrepancies were resolved by consensus. To allow subgroup analyses for identifying the optimal screening parameters, the eight national trials conducted under the umbrella of the European Randomised study of Screening for Prostate Cancer (ERSPC) were included as individual trials.

EVIDENCE SYNTHESIS

We included a total 11 randomised controlled trials (RCTs) with a total of 416 000 study participants. For all-cause mortality, we found neither benefit nor harm. PSA screening was associated with a reduced risk of both prostate cancer mortality and the development of metastases. For the outcomes of health-related quality of life, adverse effects and the consequences of false-negative screening results there was no difference; however, this was due to the lack of eligible RCT data. Finally, PSA screening was associated with large numbers of overdiagnoses with adverse downstream consequences of unnecessary treatment (e.g. incontinence, erectile dysfunction) and large numbers of false-positive PSA tests leading to biopsies associated with a small but not negligible risk of complications. Limitations of this assessment include the clinical heterogeneity and methodological limitations of the underlying studies.

CONCLUSIONS

The benefits of PSA-based prostate cancer screening do not outweigh its harms. We failed to identify eligible screening studies of newer biomarkers, PSA derivatives or modern imaging modalities, which may alter the balance of benefit to harm.

PATIENT SUMMARY

In the present study, we reviewed the evidence on the PSA blood test to screen men without symptoms for prostate cancer. We found that the small benefits experienced by some men do not outweigh the harms to many more men.

Utilization Rates of Pancreatectomy, Radical Prostatectomy, and Nephrectomy in New York, Ontario, and New South Wales, 2011 to 2018

Importance

Few studies have compared surgical utilization between countries or how rates may differ according to patients' socioeconomic status.

Objective

To compare population-level utilization of 3 common nonemergent surgical procedures in New York State (US), Ontario (Canada), and New South Wales (Australia) and how utilization differs for residents of lower- and higher-income neighborhoods.

Design, Setting, and Participants

This cohort study included all adults aged 18 years and older who were hospitalized for pancreatectomy, radical prostatectomy, or nephrectomy between 2011 and 2016 in New York, between 2011 and 2018 in Ontario, and between 2013 and 2018 in New South Wales. Each patient's address of residence was linked to 2016 census data to ascertain neighborhood income. Data were analyzed from August 2019 to November 2020.

Main Outcomes and Measures

Primary outcomes were (1) each jurisdiction's per capita age- and sex-standardized utilization rates (procedures per 100 000 residents per year) for each surgery and (2) utilization rates among residents of lower- and higher-income neighborhoods.

Results

This study included 115 428 surgical patients (25 780 [22.3%] women); 5717, 21 752, and 24 617 patients in New York were hospitalized for pancreatectomy, radical prostatectomy, and nephrectomy, respectively; 4929, 19 125, and 16 916 patients in Ontario, respectively; and 2069, 13 499, and 6804 patients in New South Wales, respectively. Patients in New South Wales were older for all procedures (eg, radical prostatectomy, mean [SD] age in New South Wales, 64.8 [7.3] years; in New York, 62.7 [8.4] years; in Ontario, 62.8 [6.7] years; P < .001); patients in New York were more likely than those in other locations to be women for pancreatectomy (New York: 2926 [51.2%]; Ontario: 2372 [48.1%]; New South Wales, 1003 [48.5%]; P = .004) and nephrectomy (New York: 10 645 [43.2%]; Ontario: 6529 [38.6%]; 2605 [38.3%]; P < .001). With the exception of nephrectomy in Ontario, there was a higher annual utilization rate for all procedures in all jurisdictions among patients residing in affluent neighborhoods (quintile 5) compared with poorer neighborhoods (quintile 1). This difference was largest in New South Wales for pancreatectomy (4.65 additional procedures per 100 000 residents [SE, 0.28]; P < .001) and radical prostatectomy (73.46 additional procedures per 100 000 residents [SE, 1.20]; P < .001); largest in New York for nephrectomy (8.43 additional procedures per 100 000 residents [SE, 0.85]; P < .001) and smallest in New York for radical prostatectomy (19.70 additional procedures per 100 000 residents [SE, 2.63]; P < .001); and smallest in Ontario for pancreatectomy (1.15 additional procedures per 100 000 residents [SE, 0.28]; P < .001) and nephrectomy (-1.10 additional procedures per 100 000 residents [SE, 0.52]; P < .001). New York had the highest utilization of nephrectomy (28.93 procedures per 100 000 residents per year [SE, 0.18]) and New South Wales for had the highest utilization of pancreatectomy and radical prostatectomy (6.94 procedures per 100 000 residents per year [SE, 0.15] and 94.37 procedures per 100 000 residents per year [SE, 0.81], respectively; all P < .001). Utilization was lowest in Ontario for all procedures (pancreatectomy, 6.18 procedures per 100 000 residents per year [SE, 0.09]; radical prostatectomy, 49.24 procedures per 100 000 residents per year [SE, 0.36]; nephrectomy, 21.40 procedures per 100 000 residents per year [SE, 0.16]; all P < .001).

Conclusions and Relevance

In this study, New York and New South Wales had higher per capita surgical utilization and larger neighborhood income-utilization gradients than Ontario. These findings suggest that income-based disparities are larger in the United States and Australia and smaller in Canada and highlight trade-offs inherent in the health care systems of different countries.

Serum Prostate-Specific Antigen Testing for Early Detection of Prostate Cancer: Managing the Gap between Clinical and Laboratory Practice

BACKGROUND

Current clinical practice guidelines (CPGs) for early detection of prostate cancer recommend for clinical decision-making a personalized prostate-specific antigen (PSA)-based management to improve the risk-benefit ratio of the screening strategy. Some important critical issues regarding the PSA determination in the clinical framework are, however, still neglected in current guidelines and a major focus of recommendations on those aspects would be needed to improve their effectiveness.

CONTENT

Evidence sources in the available literature concerning the interchangeability of total PSA results measured with different commercial methods were critically appraised. We discuss how the heterogeneity of the measurand, the intermethod bias, and the design and selectivity of immunoassays may affect the diagnostic accuracy of selected PSA thresholds, and how knowledge of the analytical characteristics of assays in service, such as the recognized PSA circulating forms and the cross-reactivity with PSA homologs, is basic for improving both clinical decision-making in cancer screening and the reliability of the clinical interpretation of results at the individual level.

SUMMARY

Current CPGs ignore the poor interchangeability of PSA results obtained from different assays and the substantial role of laboratory issues in clinical performance of PSA testing. Involved stakeholders should contribute to fill the existing gap by: (a) preparing commutable reference materials for immunoassay calibration; (b) providing analytical characteristics that may explain the different performance of assays; (c) deriving outcome-based analytical performance specifications for PSA measurement; and (d) giving more focus on laboratory items when CPGs are prepared.

Incidence and Mortality of Prostate Cancer in Canada during 1992-2010

In Canada, prostate cancer is the most common reportable malignancy in men. We assessed the temporal trends of prostate cancer to gain insight into the geographic incidence and mortality trends of this disease. Three independent population-based cancer registries were used to retrospectively analyze demographic data on Canadian men diagnosed with prostate cancer and men who died of prostate cancer between the years of 1992 and 2010. The incidence and mortality rates were calculated at the provincial, city, and forward sortation area (FSA) postal code levels by using population counts that were obtained from the Canadian Census of Population. The Canadian average incidence rate was 113.57 cases per 100,000 males. There has been an overall increasing trend in crude prostate cancer incidence between 1992 and 2010 with three peaks, in 1993, 2001, and 2007. However, age-adjusted incidence rates showed no significant increase over time. The national mortality rate was calculated to be 24.13 deaths per 100,000 males per year. A decrease was noted in crude and age-adjusted mortality rates between 1992 and 2010. Several provinces, cities, and FSAs had higher incidence/mortality rates than the national average. Several of the FSA postal codes with the highest incidence/mortality rates were adjacent to one another. Several Canadian regions of high incidence for prostate cancer have been identified through this study and temporal trends are consistent with those reported in the literature. These results will serve as a foundation for future studies that will seek to identify new regional risk factors and etiologic agents.

Patterns and Trends of Cancer Screening in Canada: Results From a Contemporary National Survey

BACKGROUND

The aim of this study was to assess the patterns and trends of colorectal, breast, and cervical cancer screening within a contemporary cohort of Canadian adults.

METHODS

Canadian Community Health Survey datasets (2007-2016) were accessed and 3 cohorts were defined: (1) a colorectal cancer (CRC) screening cohort, defined as men and women aged 50 to 74 years with complete information about CRC screening tests and their timing; (2) a breast cancer screening cohort, defined as women aged 40 to 74 years with complete information about mammography and its timing; and (3) a cervical cancer screening cohort, defined as women aged 25 to 69 years with complete information about the Papanicolaou (Pap) test and its timing. Multivariable logistic regression analysis was then performed to evaluate factors associated with not having timely screening tests at the time of survey completion.

RESULTS

A total of 99,820 participants were considered eligible for the CRC screening cohort, 59,724 for the breast cancer screening cohort, and 46,767 for the cervical cancer screening cohort. Among eligible participants, 43% did not have timely recommended screening tests for CRC, 35% did not have timely mammography (this number decreased to 26% when limiting the eligible group to ages 50-74 years), and 25% did not have a timely Pap test. Lower income was associated with not having a timely recommended screening tests for all 3 cohorts (odds ratios [95% CI]: 1.86 [1.76-1.97], 1.89 [1.76-2.04], and 1.96 [1.79-2.14], respectively). Likewise, persons self-identifying as a visible minority were less likely to have timely recommended screening tests in all 3 cohorts (odds ratios for White race vs visible minority [95% CI]: 0.87 [0.83-0.92], 0.85 [0.80-0.91], and 0.66 [0.61-0.70], respectively).

CONCLUSIONS

More than one-third of eligible individuals are missing timely screening tests for CRC. Moreover, at least one-quarter of eligible women are missing their recommended breast and cervical cancer screening tests. More efforts from federal and provincial health authorities are needed to deal with socioeconomic disparities in access to cancer screening.

[PAPPS Cancer Expert Group. Cancer Prevention Recommendations. 2020 PAPPS update]

El cáncer es una de las principales causas de morbilidad y mortalidad. El consumo de tabaco, la dieta poco saludable, la inactividad física son algunos de los factores de riesgo que forman parte del estilo de vida y que han provocado un aumento del cáncer. En este artículo se actualizan las evidencias y recomendaciones de las estrategias de prevención para cada uno de los cánceres con mayor incidencia, con base en la disminución de los factores de riesgo (prevención primaria) y en el diagnóstico precoz del cáncer, a través del cribado y la detección temprana de los signos y síntomas, en población de riesgo medio y de riesgo elevado.

Characterization and validation of long noncoding RNAs as new candidates in prostate cancer

Background

Long noncoding RNAs (lncRNAs) have been proved to be an important regulator in gene expression. In almost all kinds of cancers, lncRNAs participated in the process of pathogenesis, invasion, and metastasis. Meanwhile, compared with the large amounts of patients, there is rare knowledge about the role of lncRNAs in prostate cancer (PCa).

Material/Method

In this study, lncRNA expression profiles of prostate cancer were detected by Agilent microarray chip, 5 pairs of case and control specimens were involved in. Differentially expressed lncRNAs were screened out by volcano plot for constructing lncRNA-miRNA-mRNA central network. Then, the top ten up-regulated and down-regulated lncRNAs were validated by qRT-PCR in another 5 tumor specimens and 7 para-cancerous/benign contrasts. Furthermore, we searched for the survival curve of the top 10 upregulated and downregulated lncRNAs.

Results

A total of 817 differentially expressed lncRNAs were filtered out by the criteria of fold change (FC) and t-test p < 0.05. Among them, 422 were upregulated, whereas 395 were downregulated in PCa tissues. Gene ontology and KEGG pathway analyses showed that many lncRNAs were implicated in carcinogenesis. lnc-MYL2-4:1 (FC = 0.00141, p = 0.01909) and NR_125857 (FC = 59.27658, p = 0.00128) had the highest magnitude of change. The subsequent qPCR confirmed the expression of NR_125857 was in accordance with the clinical samples. High expression of PCA3, PCAT14 and AP001610.9 led to high hazard ratio while low expression of RP11-279F6.2 led to high hazard ratio.

Conclusions

Our study detected a relatively novel complicated map of lncRNAs in PCa, which may have the potential to investigate for diagnosis, treatment and follow-up in PCa. Our study revealed the expression of NR_125857 in human PCa tissues was most up-regulated. Further studies are needed to investigate to figure out the mechanisms in PCa.

Cohort profile: the Alberta Prostate Cancer Research Initiative (APCaRI) Registry and Biorepository facilitates technology translation to the clinic through the use of linked, longitudinal clinical and patient-reported data and biospecimens from men in Alberta, Canada

PURPOSE

The Alberta Prostate Cancer Research Initiative (APCaRI) Registry and Biorepository was established in 2014 by the APCaRI to facilitate the collection of clinical and patient-reported data, biospecimen, to measure prostate cancer outcomes and to support the development and clinical translation of innovative technologies to better diagnose and predict outcomes for patients with prostate cancer.

PARTICIPANTS

Men suspected with prostate cancer and referred to Urology centres in Alberta were enrolled in the APCaRI 01 study, while men with a prior prostate cancer diagnosis participated in the APCaRI 03 study from 1 July 2014 to 30 June 2019. The APCaRI Registry and Biorepository links biospecimens and data from a wide representation of patients drawn from an Alberta population of more than 4 million.

FINDINGS TO DATE

From 1 July 2014 to 30 June 2019, total APCaRI 01 and 03 study recruitment was 3754 men; 142 (4%) of these men withdrew in full, 65 men (2%) withdrew biospecimens and 123 men (3%) died of any cause. Over this same time, 8677 patient-reported outcome measure (PROM) surveys and 7368 biospecimens were collected and are available from the registry and biorepository, respectively. The data entry error rate was 0.8% and 0.95% for critical and non-critical values, respectively, and 1.8% for patient-reported surveys.

FUTURE PLANS

The APCaRI Registry and Biorepository will collect longitudinal data and PROM surveys until 2024, patient outcomes up to 25 years after recruitment and biospecimen storage for up to 25 years. The APCaRI cohorts will continue to provide data and samples to researchers conducting retrospective studies. The richness of the data and biospecimens will complement many different research questions, ultimately to improve the quality of care for men with prostate cancer.

Is one narrative enough? Analytical tools should match the problems they address

Jeff Nisker describes his personal experience of a diagnosis of advanced prostate cancer and the kindnesses he received from friendly doctors. He claims that this narrative account supports the promotion of Prostate Specific Antigen (PSA) screening for asymptomatic men and impugns statisticians, mistakenly thinking that their opposition to PSA screening derives from concerns about financial cost. The account inadvertently demonstrates the danger of over-reliance on a single ethical tool for critical analysis. In the first part of this response, we describe the statistical evidence. The most reliable Cochrane meta-analyses have not shown that PSA screening saves lives overall. Moreover, the high false positive rate of PSA screening leads to overinvestigation which results in unnecessary anxiety and increased cases of unnecessary sepsis, urinary incontinence and sexual dysfunction. Then we describe how narrative ethics alone is an insufficient tool to make claims about policies, such as PSA screening, which have hidden harms. Although Nisker's story-telling is compelling and evokes emotions, narrative ethics of this sort have an inherent bias against people who would be harmed by the counterfactual. Particular care must be taken to look for and consider those untellable stories. Ethicists who only consider narratives which are readily at hand risk harming those who are voiceless or protected by the status quo. PSA screening is the wrong tool to reduce prostate cancer deaths and narrative ethics is the wrong tool to appraise this policy. It is vital that the correct theoretical tools are applied to the medical and ethical questions under scrutiny.

Prostate cancer screening: guidelines review and laboratory issues

Background Prostate-specific antigen (PSA) remains as the most used biomarker in the detection of early prostate cancer (PCa). Clinical practice guidelines (CPGs) are produced to facilitate incorporation of evidence into clinical practice. This is particularly useful when PCa screening remains controversial and guidelines diverge among different medical institutions, although opportunistic screening is not recommended. Methods We performed a systematic review of guidelines about PCa screening using PSA. Guidelines published since 2008 were included in this study. The most updated version of these CPGs was used for the evaluation. Results Twenty-two guidelines were selected for review. In 59% of these guidelines, recommendations were graded according to level of evidence (n = 13), but only 18% of the guidelines provided clear algorithms (n = 4). Each CPG was assessed using a checklist of laboratory issues, including pre-analytical, analytical, and post-analytical factors. We found that laboratory medicine specialists participate in 9% of the guidelines reviewed (n = 2) and laboratory issues were frequently omitted. We remarked that information concerning the consequences of World Health Organization (WHO) standard in PSA testing was considered by only two of 22 CPGs evaluated in this study. Conclusions We concluded that the quality of PCa early detection guidelines could be improved properly considering the laboratory issues in their development.

Prediction models for prostate cancer to be used in the primary care setting: a systematic review

OBJECTIVE

To identify risk prediction models for prostate cancer (PCa) that can be used in the primary care and community health settings.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE and Embase databases combined from inception and up to the end of January 2019.

ELIGIBILITY

Studies were included based on satisfying all the following criteria: (i) presenting an evaluation of PCa risk at initial biopsy in patients with no history of PCa, (ii) studies not incorporating an invasive clinical assessment or expensive biomarker/genetic tests, (iii) inclusion of at least two variables with prostate-specific antigen (PSA) being one of them, and (iv) studies reporting a measure of predictive performance. The quality of the studies and risk of bias was assessed by using the Prediction model Risk Of Bias ASsessment Tool (PROBAST).

DATA EXTRACTION AND SYNTHESIS

Relevant information extracted for each model included: the year of publication, source of data, type of model, number of patients, country, age, PSA range, mean/median PSA, other variables included in the model, number of biopsy cores to assess outcomes, study endpoint(s), cancer detection, model validation and model performance.

RESULTS

An initial search yielded 109 potential studies, of which five met the set criteria. Four studies were cohort-based and one was a case-control study. PCa detection rate was between 20.6% and 55.8%. Area under the curve (AUC) was reported in four studies and ranged from 0.65 to 0.75. All models showed significant improvement in predicting PCa compared with being based on PSA alone. The difference in AUC between extended models and PSA alone was between 0.06 and 0.21.

CONCLUSION

Only a few PCa risk prediction models have the potential to be readily used in the primary healthcare or community health setting. Further studies are needed to investigate other potential variables that could be integrated into models to improve their clinical utility for PCa testing in a community setting.