Screening for prostate cancer: an analysis of the early experience

Intracellular MicroRNA Imaging and Specific Discrimination of Prostate Cancer Circulating Tumor Cells Using Multifunctional Gold Nanoprobe-Based Thermophoretic Assay

Circulating tumor cells (CTCs) have emerged as powerful biomarkers for diagnosis of prostate cancer. However, the effective identification and concurrently accurate imaging of CTCs for early screening of prostate cancer have been rarely explored. Herein, we reported a multifunctional gold nanoprobe-based thermophoretic assay for simultaneous specific distinguishing of prostate cancer CTCs and sensitive imaging of intracellular microRNA (miR-21), achieving the rapid and precise detection of prostate cancer. The multifunctional gold nanoprobe (GNP-DNA/Ab) was modified by two types of prostate-specific antibodies, anti-PSMA and anti-EpCAM, which could effectively recognize the targeting CTCs, and meanwhile linked double-stranded DNA for further visually imaging intracellular miR-21. Upon the specific internalization of GNP-DNA/Ab by PC-3 cells, target aberrant miR-21 could displace the signal strand to recover the fluorescence signal for sensitive detection at the single-cell level, achieving single PC-3 cell imaging benefiting from the thermophoresis-mediated signal amplification procedure. Taking advantage of the sensitive miR-21 imaging performance, GNP-DNA/Ab could be employed to discriminate the PC-3 and Jurkat cells because of the different expression levels of miR-21. Notably, PC-3 cells were efficiently recognized from white blood cells, exhibiting promising potential for the early diagnosis of prostate cancer. Furthermore, GNP-DNA/Ab possessed good biocompatibility and stability. Therefore, this work provides a great tool for aberrant miRNA-related detection and specific discrimination of CTCs, achieving the early and accurate diagnosis of prostate cancer.

Incorporating radioligand therapy in clinical practice in the United States for patients with prostate cancer

Prostate cancer (PC) is the second most commonly diagnosed cancer in the United States. Advanced PC evolves to metastatic castration-resistant PC (mCRPC). Theranostics combining prostate-specific membrane antigen-targeted positron emission tomography imaging and radioligand therapy (RLT) represents a precision medicine approach to PC treatment. With the recent approval of lutetium Lu 177 (¹⁷⁷Lu) vipivotide tetraxetan for men with mCRPC, the utilization of RLT will increase. In this review, we suggest a framework for incorporating RLT for PC into clinical practice. A search of PubMed and Google Scholar was performed using keywords related to PC, RLT, prostate-specific membrane antigen, and novel RLT centers. The authors also provided opinions based on their clinical experience. The setup and operation of an RLT center requires the diligence and cooperation of a well-trained multidisciplinary team committed to patient safety and clinical efficacy. Administrative systems should ensure that treatment scheduling, reimbursement, and patient monitoring are efficient. For optimal outcomes, the clinical care team must have an organizational plan that delineates the full range of required tasks. Establishing new RLT centers for treatment of PC is possible with appropriate multidisciplinary planning. We provide an overview of the key elements to consider when establishing a safe, efficient, and high-quality RLT center.

Improved sensitivity and specificity for prostate cancer diagnosis based on the urine PCA3/PSA ratio acquired by sequence‑specific RNA capture

Prostate cancer antigen 3 (PCA3) is a non-coding RNA fragment that is overexpressed in prostate cancer cells. However, the clinical applications of PCA3 are highly limited due to the instability of RNA and the lack of reliable and efficient RNA extraction and purification methods. Thus, in the present study, we compared three different methods of RNA extraction to further confirm the higher yield of commercial magnetic beads with poly-T functionalization and a capturer strand. The current protocols for RNA extraction of i) the phenol-chloroform method, ii) the affinity column method and iii) magnetic beads with poly-T functionalization and a capturer strand were applied separately for RNA extraction in urine samples. Reverse transcription‑quantitative polymerase chain reaction was performed to evaluate the yield of the three methods of RNA extraction. Furthermore, 52 urine samples after prostate massage from patients suspected of a diagnosis of prostate cancer were collected. The Mag-Cap method and RT-PCR were applied to obtain the PCA3 score. The clinical value of the PCA3 score was investigated by comparison with the pathology of the prostate biopsy. The yield of the Mag-Cap method was higher than that of the phenol‑chloroform method and commercial kits. Thirty‑four patients were pathologically diagnosed with prostate cancer and 18 with benign prostatic hyperplasia (BPH). It was confirmed that the median PCA3 score was higher among the prostate cancer patients than those with benign disease (53.5 vs. 17, p=0.000). A sensitivity of 82.4% and a specificity of 77.8% were obtained when the cut-off value for the PCA3 score was 28.5. The Mag-Cap method was found to be more efficient for RNA extraction. The urinary PCA3 score is a promising method for prostate cancer screening, detection and diagnosis, and has the potential to reduce unnecessary prostate biopsies.

Peripheral zone prostate cancer. Pre-treatment evaluation with MR and 3D ¹H MR spectroscopic imaging: correlation with pathologic findings

The purpose of this study was to retrospectively characterize benign and malignant prostate peripheral zone tissue by using endorectal MRI and 3D ¹H MRS. Fifty-two men with untreated biopsy-proven prostate cancer underwent combined endorectal MRI and MRSI. Whole-mount step-section histopathologic analysis constituted the reference standard. Biopsy correctly detected 74 locations; MRI correctly detected 72 locations; MRS correctly detected 72 locations; MRI + MRS correctly detected 78 locations. Cohen's test showed that biopsy had a lower degree of agreement with histology than MRI + MRS combined. The ratio of [(Cho + Cr)]/Cit correlates with the pathologic Gleason score. The addition of 3D¹H MRSI to MRI can improve diagnosis of prostate cancer contributing indirectly to improve local staging. In addition, the correlation between metabolic 3D¹H MRSI data with pathological Gleason grade may offer a non-invasive means to better predict prostate cancer aggressiveness.

Should Men with Serum Prostate-Specific Antigen ≤4 ng/ml and Normal Digital Rectal Examination Undergo a Prostate Biopsy?

The clinical significance of a prostate cancer (PCa) cannot be determined solely by tumor volume (< or =0.5 cm(3)), as small tumors of higher Gleason grade and tumors occurring in younger men may become clinically significant even though the initial volume at diagnosis is small. A certain number of these minimal cancers are likely to remain clinically insignificant; however, it is unpredictable how many can progress beyond the curable stage by the time there is a rise in serum prostate-specific antigen (PSA) values. Compared to clinically detected PCa, PCa detected exclusively by PSA screening (clinical stage T1c) are less likely to be advanced but no more likely to be insignificant in terms of volume, pathologic stage, and Gleason pattern. Only 10-15% of PSA-detected cancers have the features of PCa found at autopsy or in cystoprostatectomy specimens. Actually, 25-30% of PCa are detected with PSA values between 2.5 and 4 ng/ml, and most of these cancers are clinically significant. Evidence from both retrospective and longitudinal studies has shown that the risk of a PCa is dependent on the patient's age and the initial serum PSA. This allows an individualized approach to PCa screening programs, and PSA cutoff values for biopsy indication may be lowered in selected patients.

Prognostic value of carbonic anhydrase IX and KI67 as predictors of survival for renal clear cell carcinoma

PURPOSE

The natural history of renal cell carcinoma (RCC) is complex and not entirely explained by conventional prognostic factors. In this study we evaluated the prognostic value of carbonic anhydrase IX (CAIX) and Ki67 to predict survival in RCC.

MATERIALS AND METHODS

Immunohistochemical analysis using a CAIX and a Ki67 monoclonal antibody was performed on tissue microarrays constructed from paraffin embedded specimens from 224 patients treated with nephrectomy for clear cell renal carcinoma. CAIX and Ki67 staining were correlated with clinical factors, pathological features and survival. Median followup was 34 months (range 0.3 to 117) and disease specific survival was the primary end point assessed.

RESULTS

Univariate statistical analysis showed that high Ki67 staining and low CAIX staining correlated significantly with poor median survival (21 months, p < 0.001 and 22 months, p = 0.011, respectively). Each marker was highly significant for stratifying patient groups defined by T stage, Fuhrman grade, nodal status, metastatic status and performance status. On multivariate analysis CAIX and Ki67 were significant predictors of survival with an HR of 1.78 (p = 0.014) and 1.75 (p = 0.009), respectively. Although CAIX and Ki67 staining were inversely correlated (p = 0.009), Ki67 significantly substratified patient subgroups defined by high or low CAIX staining (p = 0.001 and 0.003, respectively). When Ki67 and CAIX were combined into a single parameter, RCC tumors could be stratified into low, intermediate and high risk groups with a median survival of greater than 101, 31 and 9 months, respectively (p <0.001). On multivariate analysis the combined parameter consisting of Ki67 and CAIX was a significant predictor of survival (p <0.001) and it was able to displace histological grade.

CONCLUSIONS

Ki67and CAIX are useful prognostic biomarkers for RCC that improve the survival prediction and classification of kidney cancer.

Screening for prostate cancer: Updated experience from the Tyrol study

The aim of the Tyrol study was to monitor the impact of screening in a natural experiment by comparing prostate cancer mortality in Tyrol, where prostate-specific antigen (PSA) testing was introduced at no charge, with the rest of Austria, where it was not strictly organized and not free of charge. In 1993, PSA testing was made freely available to men between the ages of 45 and 75 years in the Federal State of Tyrol, Austria. At least 70% of all of the men in this age range have been tested at least once during the first 10 years of the study. Initially, only total PSA was measured, but free PSA measurement was added in 1995. Since 2001, complexed PSA also has been measured. Digital rectal examination was not part of the screening examination. Significant migration to lower clinical and pathological stages has been observed since the introduction of this screening program. These findings are consistent with the hypothesis that the policy of making PSA testing freely available, and the wide acceptance by men in the population, is associated with a reduction in prostate cancer mortality in an area in which urology services and radiotherapy are available freely to all patients. It is our opinion that most of this decline is likely a result of aggressive downstaging and successful treatment and that any contribution from detecting and treating early cancers will become apparent in the years to come.

System for MR image-guided prostate interventions: canine study

The purpose of this study was to demonstrate the use of a transrectal system that enables precise magnetic resonance (MR) image guidance and monitoring of prostate interventions. The system used a closed-bore 1.5-T MR imaging unit and enables one to take advantage of the higher signal-to-noise ratio achieved with traditional magnet designs, which is crucial for accurate targeting and monitoring of prostate interventions. In the first of the four canine studies, reliable needle placement, with all needles placed within 2 mm of the desired target site, was achieved. In two other studies, MR imaging was used to monitor distribution of injected contrast agent solution (gadopentetate dimeglumine mixed with trypan blue dye) in and around the prostate, thereby confirming that solution had been delivered to the desired tissue and also detecting faulty injections. In the final study, accurate placement and MR imaging of brachytherapy seeds in the prostate were demonstrated. The described system provides a flexible platform for a variety of minimally invasive MR image-guided therapeutic and diagnostic prostate interventions.

Screening for prostate cancer with prostate-specific antigen: beware the biases

BACKGROUND

The evidence relating to the use of prostate-specific antigen (PSA) as a screening test is a highly controversial, as demonstrated by the lack of agreement among experts. There may be biases associated with various studies.

ISSUES

The main controversy is the relatively high prevalence of prostate cancer (PC) found at autopsy compared with the relatively low death rate from the disease. The lack of modifiable risk factors has led to early detection as a strategy to reduce mortality, as there is evidence for a significant burden of disease. Important issues are the accuracy of current screening tests, some attempts to improve on them, and whether there are good prognostic markers. The consequences of PSA testing (usually further testing including biopsy) and outcomes of treatment are presented in terms of mortality and morbidity; quality of life (QOL) must also be considered. Also important are the benefits from, and the difficulties associated with the "informed choice" approach to PSA screening.

CONCLUSION

There is evidence to suggest that biases can have a significant impact on the utility of PSA as a screening test for PC.

Prostate cancer mortality after introduction of prostate-specific antigen mass screening in the Federal State of Tyrol, Austria

OBJECTIVES

To monitor the impact of screening in a natural experiment by comparing prostate cancer mortality in Tyrol, where prostate-specific antigen (PSA) testing was introduced at no charge, with the rest of Austria, where it was not introduced.

METHODS

In 1993, PSA testing was made freely available to men aged 45 to 75 years in the Federal State of Tyrol, Austria. At least two thirds of all men in this age range have been tested at least once during the first 5 years of the study. Initially, only total PSA was measured, but free PSA measurement was added in 1995. The IMX assay was used. Digital rectal examination was not part of the screening examination.

RESULTS

Significant migration to lower stages has been observed since the introduction of this screening program. A reduction in mortality rates in the rest of Austria from 1993 onward has occurred, with the reduction in Tyrol much greater; the mortality remained fairly constant between 1993 and 1995 and subsequently fell. The trends in prostate cancer mortality rates since 1993 differ significantly between Tyrol (P = 0.006) and the rest of Austria. On the basis of the age-specific death rates averaged from 1986 to 1990, the difference between the number of expected and observed deaths from prostate cancer in Tyrol was 22 in the group aged 40 to 79 years in 1998 and 18 the following year.

CONCLUSIONS

These findings are consistent with the hypothesis that the policy of making PSA testing freely available, and the wide acceptance by men in the population, is associated with a reduction in prostate cancer mortality in an area in which urology services and radiotherapy are available freely to all patients. It is our opinion that most of this decline is likely to be due to aggressive downstaging and successful treatment and that any contribution from detecting and treating early cancers will only become apparent in the years to come.

Magnetic resonance imaging and spectroscopic imaging: Improved patient selection and potential for metabolic intermediate endpoints in prostate cancer chemoprevention trials

In the design of prostate cancer chemoprevention trials there is a clear need for improved patient selection and risk stratification, as well as the use of biomarkers that could provide earlier assessment of therapeutic efficacy. Studies in preprostatectomy patients have indicated that the metabolic information provided by 3-dimensional magnetic resonance spectroscopic imaging (3D-MRSI) combined with the morphologic information provided by magnetic resonance imaging (MRI) can improve the assessment of cancer location and extent within the prostate, extracapsular spread, and cancer aggressiveness. Additionally, pre- and posttherapy studies have demonstrated the potential of MRI/3D-MRSI to provide a direct measure of the presence and spatial extent of prostate cancer after therapy, a measure of the time course of response, and information concerning the mechanism of therapeutic response. These studies suggest that the addition of MRI/3D-MRSI data to prostate-specific antigen and biopsy data may improve patient selection and risk stratification for chemoprevention trials, improve tissue sampling for ex vivo molecular marker analysis, and provide shorter-term endpoints in chemoprevention trials. However, future studies are necessary to establish the ability of MRI/3D-MRSI to accurately assess patients with premalignant or very early malignant changes, to validate metabolic markers as intermediate endpoints in chemoprevention trials, and to correlate metabolic endpoints with other promising intermediate biomarkers.

Prostate cancer: screening and early detection

BACKGROUND

Despite more than a decade of prostate-specific antigen (PSA)-based screening, the proven impact of screening on mortality due to prostate cancer continues to be controversial.

METHODS

A literature review of issues pertaining to the epidemiology, screening, early detection, and mortality as they relate to prostate cancer was conducted. Included in the review are PSA refinements, controversies of screening, and organization guidelines. Finally, recent reports of mortality rates in the post-PSA era are presented for discussion.

RESULTS

Prostate cancer mortality rates have begun to decline for the first time since statistics have been recorded. The recent decline in age-adjusted mortality rates from prostate cancer is significant, and this decline appears to be earlier than would have been predicted. This finding, coupled with the dramatic decline in metastatic disease, implies that PSA-based screening may be responsible for a significant portion of this improvement in mortality.

CONCLUSIONS

The cost of prostate cancer screening appears to be acceptable. Randomized studies of PSA-based screening are currently ongoing, although the results may not be available for a decade. Currently, the best evidence is derived from population-based studies that appear to show a benefit to prostate cancer screening.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Biomarkers of renal cell carcinoma. Past and future considerations

Renal cancer includes several distinct entities with a range of biologic and clinical behaviors from relatively indolent to extremely aggressive tumors. Although conventional prognostic factors such as stage and grade are quite useful, other clinical, laboratory, and pathologic findings are now believed to have additional predictive values. This article reviews the literature on the potential utility of biomarkers in renal cell carcinoma. To date, only a few biomarkers, such as Ki-67, appeared to be potentially useful for monitoring renal cancer patients. New biomarkers including MN/CA9 and circulating cell detection require further and extensive studies to assess their potential clinical utility.

Prostate carcinoma trends in three counties in Sweden 1987-1996: results from a population-based national cancer register. South-East Region Prostate Cancer Group

BACKGROUND

To detect changes in the incidence rate and management of prostate carcinoma, all cases of the disease diagnosed in the southeast region of Sweden between 1987-1996 were recorded.

METHODS

The register is based on Swedish personal registration numbers, thereby minimizing the number of dropouts. All cases of prostate carcinoma detected in the southeast region have been recorded according to a defined protocol that has been updated successively to match recent views regarding the disease. To ensure a high number of presented cases, the National Cancer Register was checked for missing cases.

RESULTS

Six thousand seven hundred eighty-two cases of prostate carcinoma were registered in the region between 1987-1996. The age-adjusted incidence rate reached a peak in 1993, followed by a slight decrease. The mean age at diagnosis throughout the period was 74.2 years, with a peak age of 74.8 years in 1992. The number of incidental tumors followed the development of the number of transurethral resections of the prostate performed in the region, with a peak in 1991. The percentage of patients receiving gonadotropin-releasing hormone (GnRH) analogues increased from 3.9% to 37.8% whereas the percentage of patients treated with orchiectomy decreased from 40.0% to 12.8% and the percentage of those treated with radical prostatectomy decreased from 11.1% to 2.5%.

CONCLUSIONS

A diminishing pool of latent tumors may explain the decreasing incidence rate and lower age at diagnosis observed after 1993. Orchiectomy is rapidly being superseded by GnRH analogues. In contrast to trends reported in the U.S., the percentage of men with prostate carcinoma undergoing total prostatectomy appears to be declining in Sweden.

Imaging prostate cancer

In the detection of prostate cancer, the most important role of imaging is ultrasound-guided prostatic biopsy. In the staging evaluation of prostate cancer, each presently used modality--transrectal US (TRUS), MR imaging, CT, nuclear medicine, and positron emission tomography--has advantages and disadvantages. Evidence-based guidelines on the use of CT and nuclear medicine bone scan, in assessing the risk of distant spread of prostate cancer, are available. There is no consensus and there are no guidelines, however, for the use of imaging in the evaluation of prostate cancer local tumor extent. Results on the value of TRUS vary widely, and prospective multicenter studies suggest that TRUS is no better than digital rectal examination in predicting extracapsular extension. MR imaging offers the most promise for local staging of prostate cancer, but it must resolve problems of reproducible image quality and interobserver variability, and it should prove its efficacy in multicenter trials before it can be recommended for general clinical use. The introduction of MR spectroscopic imaging further expands the value of MR imaging, offering anatomic and metabolic evaluation of prostate cancer.

Comparison of clinically nonpalpable prostate-specific antigen-detected (cT1c) versus palpable (cT2) prostate cancers in patients undergoing radical retropubic prostatectomy

OBJECTIVES

Serum prostate-specific antigen (PSA) testing has led to increased detection of clinically localized prostate cancer. We analyzed the clinical characteristics and outcome of digitally palpable (cT2) and PSA detected (cT1c) prostate cancers.

METHODS

We evaluated 4453 patients with clinically localized prostate cancer who underwent radical retropubic prostatectomy (RRP) between 1987 and 1995 at the Mayo Clinic. Overall, 1041 (23.4%), 1076 (24.2%), and 2336 (52.5%) patients had cT1c, cT2a, and cT2b/c disease, respectively. Patients were analyzed with regard to Gleason score, preoperative PSA, pathologic stage, deoxyribonucleic acid (DNA) ploidy, margin status, tumor volume, and adjuvant treatment. Survival outcomes at 5 and 7 years were estimated using the Kaplan-Meier method with respect to the end points of systemic/local clinical progression and clinical and/or PSA progression (greater than 0.2 microg/mL). Multivariate analysis was employed to estimate the relative risk of progression associated with each clinical stage when adjusted for the above factors.

RESULTS

Clinical T1c tumors were more likely to be organ confined (76% versus 54%), have a Gleason score less than 7 (75% versus 61%), and be diploid (80% versus 70%) than cT2b/c tumors (P <0.001). Clinical T1c disease closely resembled cT2b/c disease with respect to preoperative PSA. Considering pathologic stage, DNA ploidy, and tumor volume, cT1c tumors were comparable to cT2a lesions. Of the patients with T1c cancers, 96.2% had clinically significant cancer on the basis of pathologic grade and tumor volume. The 5 (and 7 year) systemic/local clinical progression-free and PSA progression-free survivals for cT1c tumors were 97.7+/-0.7% (96.4+/-1.1%) and 82.2+/-1.7% (72.9+/-3.8%), respectively. There was a significant survival advantage at 5 and 7 years regarding both end points for cT1c and cT2a compared with cT2b/c tumors (P <0.001). Multivariate analysis revealed a continued benefit in PSA and systemic/local clinical progression for cT1c tumors compared with cT2b/c tumors adjusting for the above factors.

CONCLUSIONS

Clinical T1c tumors are clinically significant cancers. When compared with digitally palpable tumors, progression-free survival rates for cT1c tumors are similar to cT2a lesions, but are significantly better than cT2b/c lesions. This supports continued use of serum PSA to detect potentially curable prostate cancer.

Perceived benefits: a predictor of participation in prostate cancer screening

Prostate cancer is the most frequently diagnosed major cancer and the second cause of cancer-related deaths among men. With early detection through screening and timely treatment, 9 out of 10 men will survive a minimum of 5 years. However, with late diagnoses, only 3 out of 10 men will have a 5-year minimum survival rate. Guided by a conceptual map, this correlational research examined perceived benefits as a predictor of participation in free prostate cancer screening. Perceived benefits are the personal belief and valuing of screening for early detection of prostate cancer. All subjects received one of four educational interventions: traditional, peer educator, client navigator, or combination. Participation in prostate cancer screening was measured by compliance with the American Cancer Society's Guidelines, which included a digital rectal exam (DRE) and/or a prostate-specific antigen (PSA) blood test. The purposive sample (n = 1,522) of men, ages 40 to 70 years, was recruited from randomly selected churches, barbershops, industries, housing projects, and car dealerships in a southeastern state. Seventy-two percent of the sample was African American. Predictors of participation in free prostate cancer screening were these: perceived benefits, being white, having at least a high school education, being married, and receiving the client navigator or combination educational intervention. The Benefits Scale was significant (p = 0.013, odds ratio (OR) = 1.059) as a predictor for participation in screening when all demographic variables and educational interventions were controlled. Practice implications for nursing are discussed and recommendations for future research are presented.

Prostate cancer education in African American churches

The use of churches as recruitment sites of African Americans into health promotion activities is a popular theme in the 1990s literature. This research measured the impact of previous exposure to cancer on participation in an educational program and a free prostate cancer screening. Cues to action from the Health Belief Model provided the conceptual framework. Over 500 men attended a prostate cancer educational program at their church. Men who participated in the educational program and completed the questionnaire were given a voucher that they could take to their doctor of choice for a free prostate cancer examination. Having a member of the congregation who was previously diagnosed with cancer was a significant cue to attendance at the educational program (P = 0.03). Recommendations for future cancer screening in churches are given.

Influence of prostate-specific antigen testing on the spectrum of patients with prostate cancer undergoing radical prostatectomy at a large referral practice

OBJECTIVE

To analyze trends in the clinical stage and pathologic outcome of patients with prostate cancer who underwent radical prostatectomy at a large referral practice during the prostate-specific antigen (PSA) testing era.

MATERIAL AND METHODS

Between January 1987 and June 1995, 5,568 patients with prostate cancer (4,774 with clinically localized disease of stage T2c or less) underwent pelvic lymphadenectomy and radical retropubic prostatectomy at our institution. Patient age, preoperative serum PSA level, clinical stage, pathologic stage, Gleason score, and tumor ploidy were assessed. Outcome was based on clinical and PSA (increases in PSA level of 0.2 ng/mL or more) progression-free survival.

RESULTS

Patient age (65 to 63 years old; P<0.001) and serum PSA level (median, 8.4 to 6.8 ng/mL; P<0.001) decreased during the study period. The percentage of patients with clinical stage T1c prostate cancer increased from 2.1% in 1987 to 36.4% in 1995 (P<0.001), and clinical stage T3 cancer decreased from 25.3% to 6.5% (P<0.001). Nondiploid tumors decreased from 38.3% to 24.6% (P<0.001), and the proportion of patients with pathologically organ-confined disease increased from 54.9% to 74.3% (P<0.001). More cT1c than cT2 tumors were diploid (80% versus 72%; P<0.001), had a Gleason score of 7 or less (75% versus 65%; P<0.001), and were confined to the prostate (75% versus 57%; P<0.001). Five-year progression-free survival was 85% and 76% for patients with clinical stage T1c and T2, respectively (P<0.001).

CONCLUSION

Since the advent of PSA testing, patients referred to our institution for radical prostatectomy have shown a significant migration to lower-stage, less-nondiploid, more often organ-confined prostate cancer at the time of initial assessment. Cancer-free survival associated with PSA-detected cancer (cT1c) is superior to that with palpable tumors (cT2). Whether these trends translate into improved long-term cancer-specific survival remains to be confirmed with longer follow-up.

Detection of breast cancer at a smaller size can reduce the likelihood of metastatic spread: a quantitative analysis

RATIONALE AND OBJECTIVES

The authors extrapolated the lognormal relationship between size of tumor and probability of metastasis to include small tumors.

METHODS

Extrapolation was performed by using linear weighted regression analysis techniques to estimate prediction intervals for the predicted probabilities.

RESULTS

Tumors detected at 1 cm in diameter had a 7.31% probability of metastasis (95% prediction interval [PI], 4.36% to 11.6%). Tumors detected at 5 mm in diameter had a 1.23% probability of metastasis (95% PI, 0.45% to 3.0%). Tumors detected at 2 mm had a 0.049% probability of metastasis (95% PI, 0.00705% to 0.267%).

CONCLUSION

This analysis shows a major reduction in metastasis probability when tumors are detected at small sizes. These results suggest that detection of very early tumors can substantially reduce the likelihood of metastatic spread.

Screening for prostate cancer is neither appropriate nor cost-effective

Seen from a societal perspective, the health gains that might result from prostate screening are too uncertain to justify the substantial associated costs and adverse health effects. Clinicians who rely on observational screening studies to justify current screening practices should be aware of the potential biases that render conclusions suspect. Medical history documents numerous cases of medical interventions that appeared reasonable at the time, but ultimately proved worthless and even harmful. Before embarking on an ambitious screening program for prostate cancer, clinicians should demand that five basic criteria are satisfied: (1) that prostate cancer is a significant health burden, (2) that screening can identify localized disease, (3) that tests used in screening programs have acceptable performance among the population being tested, (4) that the potential for cure is greater among patients with screen-detected disease, and (5) that screen-detected patients have improved health outcomes compared with those who are not screened. Randomized trials provide the best methodology for determining the efficacy of screening and treatment. Clinicians are often too quick to credit medical intervention for successful outcomes and blame tumor biology for disease progression. Furthermore, when faced with a decision of administering or withholding therapy, physicians generally wish to err on the side of having done everything possible. Data modeling can provide critical insights concerning these issues using currently available information. Three recently published models suggest that the overall benefit to a population of men screened for prostate cancer can be measured in days of additional time of life gained, not months or years. Furthermore, models suggest that a substantial number of men need to undergo treatment in order to avert a single cancer death. The costs of implementing a screening program are enormous and deflect resources away from alternative uses, such as increased basic science funding to identify a cure for this disease. Therefore, based on the evidence presented, I believe that without more substantial data supporting the efficacy of screening programs, screening for prostate cancer is neither appropriate nor cost-effective.

A national survey of attitudes regarding participation in prostate carcinoma testing

BACKGROUND

The prevalence of prostate carcinoma testing is rapidly changing. Little is known about the frequency of testing in the non-Medicare population in the United States. The current study was conducted for a better understanding of who is being tested and some of the reasons why.

METHODS

A randomized national telephone survey was administered to 800 men by the George H. Gallup International Institute. Questions in the survey were evaluated for their association with participation in prostate carcinoma testing reported by the men interviewed.

RESULTS

Participation in prostate carcinoma testing approximated the frequency of colon carcinoma testing Eighty-six percent of the men surveyed believed that prostate carcinoma is a serious malignancy, and 78% believed that it could be cured often if detected early. Multivariate logistic regression models identified six factors that increased the likelihood of men in the survey being tested: white race, willingness to be tested, previous conversation with a physician or health professional, having had serum cholesterol tested, having been tested for colon carcinoma, and belonging to successively advanced age groups.

CONCLUSIONS

Prostate carcinoma testing is commonly performed in men older than 40 years. Physician counsel and patient prevention consciousness appear to be the major influences when a patient decides to be tested. If early detection is considered beneficial, special efforts would be needed to reach the nonwhite population.

Trends in the stage specific incidence of prostate carcinoma in the Detroit metropolitan area, 1973-1994

BACKGROUND

Much of the recent increase in prostate carcinoma incidence has been attributed to screening with prostate specific antigen (PSA). Controversy exists as to whether this screening will ultimately impact prostate carcinoma mortality. Until adequate time elapses since PSA screening became widespread, or a randomized trial of PSA screening is completed, the effect of PSA screening on prostate carcinoma mortality cannot be determined. In the interim, stage specific prostate carcinoma incidence rates may provide an indication of the effect of PSA screening.

METHODS

Annual stage specific age-adjusted prostate carcinoma incidence rates for the years 1973 through 1994 were obtained from the Metropolitan Detroit Cancer Surveillance System (MDCSS), a member of the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program. These incidence rates were analyzed for trends using Poisson regression analysis.

RESULTS

There were 10,801 cases of prostate carcinoma in black men and 31,501 in white men during the 22-year period. Incidence rates for stages of local and regional prostate carcinoma reached a maximum in 1992 and 1993. Distant stage prostate carcinoma incidence has steadily declined since 1989 (P < 0.001), the year in which the increasing trend in the incidence rates for local and regional stage prostate carcinoma were first noted.

CONCLUSIONS

These findings suggest that a substantial proportion of early stage prostate carcinoma detected by PSA is in fact clinically important and that early detection of these carcinomas has resulted in a continuous decline in the stage of metastatic prostate carcinoma since 1989.

Factors associated with intention to undergo annual prostate cancer screening among African American men in Philadelphia

BACKGROUND

This study assesses whether African American men in Philadelphia are receptive to annual prostate cancer screening. Factors associated with intention to undergo prostate cancer screening are also identified.

METHODS

The authors randomly selected 218 African American men from the patient population of a large primary care practice in Philadelphia. The men were 40 to 70 years of age and were available for a telephone survey. Responses to survey items defined by the Preventive Health Model were collected from 154 respondents (71%). Univariate and multivariate analyses of screening intention were performed using survey data on sociodemographic background and medical history; knowledge, attitudes, and beliefs about prostate cancer and screening; social support and influence; and, intention to undergo a screening examination.

RESULTS

Overall, 69% of subjects reported that they intended to have annual prostate cancer screening. Logistic regression analyses showed that subject belief in screening efficacy (P=0.0002) were positively and significantly associated with intention to screen.

CONCLUSIONS

Findings reported here show that African American men in an urban primary care practice setting are receptive to annual prostate cancer screening and that psychologic and social influence factors are associated with screening intention. The data highlight the need for health care professionals to provide education and advice regarding prostate cancer care to men in this population.

Management of prostate and bladder cancer in the elderly

The management of prostate and bladder cancer in the elderly will increasingly require clinicians to judge the impact on comorbidity and toxicity of the proposed therapy in order to make sound management decisions. As PSA-based screening has rapidly increased, physicians are increasingly challenged to decide the upper age limits for such screening and therapy. Bladder cancer management in the elderly differs little from that offered to the younger patient and the new therapeutic developments may improve the risk-to-benefit ratio of treating advanced disease. It is clear that as the US population ages, management of prostate and bladder cancer will become an increasingly common dilemma for the urologic practitioner.

Prostate cancer screening

Prostate cancer is a common cancer and a leading cause of cancer death in men. It is potentially detectable at early, possibly curative stages through various combinations of testing, including DRE, PSA, and TRUS of the prostate. Still unproven is the effectiveness of prostate cancer treatment, and because of that lack of proof, the optimal screening strategies are also elusive. It is possible that what is known as prostate cancer today may be, in fact, multiple entities with different natural histories, different treatment needs, and, consequently, different screening strategies. The role of informed consent has been suggested as a means to involve patients in the decision process, especially because the literature presents an environment of intense controversy. It is hoped that the PIVOT trial or similar efforts and further research into the basic mechanisms of the disease will provide clearer answers in the future.