Risk of prostate cancer for young men with a prostate specific antigen less than their age specific median

PURPOSE

We previously reported that the median prostate specific antigen for men 40 to 49 years old is 0.7 ng/ml and that a baseline prostate specific antigen between 0.7 and 2.5 ng/ml is associated with a 14.6-fold increased risk of prostate cancer. Although this suggests the need for close followup of men in their 40s with a prostate specific antigen level greater than 0.7 ng/ml, the appropriate screening strategy for men with a level less than the age specific median is unclear.

MATERIALS AND METHODS

From a large prostate cancer screening study 581 participants 40 to 49 years old with a baseline prostate specific antigen level less than 0.7 ng/ml were identified. All men were classified as high risk due to a positive family history and/or black heritage. Changes in prostate specific antigen over time, the cancer detection rate and pathological tumor features were examined as a function of the baseline prostate specific antigen.

RESULTS

At a median followup of 13 months 2 patients with an initial prostate specific antigen level less than 0.7 ng/ml reached the threshold for biopsy, and a single patient was diagnosed with prostate cancer. A significantly greater proportion of men with a baseline prostate specific antigen level greater than the age specific median had a prostate specific antigen velocity greater than 0.75 ng/ml per year (9% vs 3%, p=0.009) and were diagnosed with prostate cancer before age 50 (4.6% vs 0.16%, p<0.0001).

CONCLUSIONS

Men 40 to 49 years old with a prostate specific antigen less than the age specific median have a low risk of prostate cancer in the short term. Performing a baseline prostate specific antigen measurement in the fifth decade led to few additional biopsies, and was extremely useful for risk stratification since men with levels greater or less than the age specific median had strikingly different risk profiles.

Prostate Specific Antigen Density Correlates With Features of Prostate Cancer Aggressiveness

PURPOSE

An increased prostate specific antigen density (serum prostate specific antigen divided by prostate volume) is an established parameter to help determine the need to perform prostate biopsies. A man with a high prostate specific antigen and a normal size prostate gland is more likely to have cancer than a man with the same prostate specific antigen and a large gland. Prostate specific antigen in relation to prostate size should also reflect the volume of cancer in the gland. One group defined clinically unimportant prostate cancer as tumor volume less than 0.5 cc, organ confined disease and Gleason less than 7. Another group noted that at the time of biopsy, a prostate specific antigen density less than 0.15 ng/ml/cc combined with low risk clinical tumor features predicted insignificant cancer. There are limited published validating data on the association of prostate specific antigen density with the criteria for prostate cancer aggressiveness. We tested the association of prostate specific antigen density with features of tumor aggressiveness in a screened and in a nonscreened cohort of patients with clinically localized prostate cancer treated with radical prostatectomy.

MATERIALS AND METHODS

The screened patient cohort included 1,280 patients with screen detected prostate cancer treated from 1990 to 2002 at Washington University, and the nonscreened cohort included 382 patients treated from 2003 to 2004 at Northwestern University. We recorded the clinical and pathological tumor parameters in a prospective database. Parameters evaluated were pathological tumor stage, Gleason sum, tumor volume, biochemical progression and the previously mentioned 2 criteria for clinically unimportant cancers. We grouped patients into 4 prostate specific antigen density categories of less than 0.1, 0.1 to 0.14, 0.15 to 0.19 and greater than 0.19 ng/ml/cc.

RESULTS

There was a significant trend for worsening clinicopathological prognostic features as prostate specific antigen density increased. There were 357 (82%), 283 (75%), 171 (75%) and 192 (55%) men with organ confined disease with clear surgical margins if prostate specific antigen density was less than 0.1, 0.1 to 0.14, 0.15 to 0.19 and greater than 0.19 ng/ml/cc, respectively (p <0.001). There were 86 (20%), 102 (27%), 64 (28%) and 157 (45%) men with a Gleason sum greater than 7 when grouped into each increasing PSA density category, respectively (p <0.001). There were 91 (21%), 91 (25%), 74 (33%) and 157 (46%) men with a total cancer volume greater than 0.5 cc when grouped into each increasing PSA density category, respectively (p <0.001). Prostate specific antigen velocity was greater than 2 ng/ml per year in 11%, 30%, 27% and 46% of men if prostate specific antigen density was less than 0.1, 0.1 to 0.14, 0.15 to 0.19 and greater than 0.19 ng/ml/cc, respectively (p <0.001).

CONCLUSIONS

Prostate specific antigen density measurements are useful in helping to determine the aggressiveness of clinically localized prostate cancer, and can be used as an adjunct in predicting insignificant cancer and outcomes after local therapy.

Characteristics of patients with familial versus sporadic prostate cancer

PURPOSE

There are conflicting reports concerning whether prostate cancer in families with multiple affected members has different clinical and pathological features than sporadic cases. In our study we compared the clinical characteristics, pathological outcomes and the 7-year biochemical progression-free rate in patients with apparent sporadic prostate cancer, affected sibling pairs, families with multiple affected members and families meeting the Johns Hopkins criteria for hereditary prostate cancer.

MATERIALS AND METHODS

From 1983 to 2003, 3,478 men underwent radical retropubic prostatectomy by a single surgeon (WJC). Of these men 1,186 reported family history status. We compared age at surgery, prostate specific antigen at diagnosis, pathological tumor stage, Gleason score, tumor characteristics and 7-year biochemical progression-free survival rates in the groups using chi-square, 1-way ANOVA or Cox proportional hazards regression analysis.

RESULTS

The 7-year biochemical progression-free survival rates were 81% for sporadic cases, 71% for sibling pairs, 72% for hereditary cases and 81% for high density family members (p = 0.3). Of the clinical and pathological features examined only age (p <0.0001) and positive surgical margin rate (p = 0.03) were significantly different among groups.

CONCLUSIONS

In our study population clinicopathological features and progression-free survival are similar between sporadic and familial prostate cancer cases. The sibling pairs had a trend toward less favorable tumor features and progression-free survival, but the difference was not statistically significant.

Survival results in patients with screen-detected prostate cancer versus physician-referred patients treated with radical prostatectomy: Early results

OBJECTIVE

Screening using a standardized protocol may improve outcomes of patients undergoing treatment for prostate cancer. We compared the 7- year progression-free survival rates after radical retropubic prostatectomy in patients whose prostate cancer was detected through a formal screening program with those of patients referred for treatment by other physicians who did not use a standardized screening/referral protocol.

METHODS

A single surgeon (W.J.C.) performed radical retropubic prostatectomy in 3,177 consecutive patients between 1989 and 2003. Of these patients, 464 had cancer detected in a screening study, and 2,713 were referred from outside institutions. We compared the screened and referred cohorts for age at surgery, clinical stage, pathologic stage, Gleason sum, preoperative prostate-specific antigen (PSA) levels, and adjuvant radiation therapy. Kaplan-Meier product limit estimates were used to calculate 7-year progression-free probabilities, and Cox proportional hazards models were used to determine the clinical and pathologic parameters associated with cancer progression in each group.

RESULTS

The overall 7-year progression-free survival rates were 83% for the screened patients compared with 77% for the referred patients (P = 0.002). Preoperative PSA, Gleason sum, clinical stage, pathologic stage, and adjuvant radiotherapy were all significantly associated with cancer progression. There was a significantly higher proportion of referred patients with a preoperative PSA > or =10, Gleason sum > or =7, and nonorgan-confined disease.

CONCLUSIONS

Patients with screened-detected prostate cancer have more favorable clinical and pathologic features, and 7-year progression-free survival rates than referred patients. On multivariate analysis, including other clinical variables, screening status was a significant independent predictor of biochemical outcome.

Lymphovascular invasion in radical prostatectomy specimens: Prediction of adverse pathologic features and biochemical progression

OBJECTIVES

Patients and referring physicians often ask about the significance of lymphovascular invasion (LVI) on pathology reports from radical prostatectomy specimens. However, limited data are available concerning the relationship between LVI and preoperative screening characteristics, pathologic tumor features, and patient prognosis.

METHODS

LVI was evaluated for its ability to predict elevated prostate-specific antigen velocity, adverse pathologic features, and biochemical progression in 1709 men who underwent radical prostatectomy for clinically localized disease.

RESULTS

LVI was present in 118 (7%) of the 1709 men. On univariate analysis, LVI was significantly associated with tumor grade, tumor volume, and other adverse pathologic features. Prostate-specific antigen velocity was not significantly associated with the presence of LVI. Biochemical progression occurred in 34% of those with LVI compared with 10% of those without LVI (P <0.0001). However, on multivariate analysis with other pathologic tumor features, LVI was not an independent predictor of progression.

CONCLUSIONS

LVI is a relatively uncommon finding in radical prostatectomy specimens for clinically localized disease. Although LVI was seen primarily in large-volume, high-grade tumors, it was not an independent predictor of progression in the multivariate model.

1-Methyl-4-phenyl-1,2,3,6-tetrahydropyridine-induced acute transient dystonia in monkeys associated with low striatal dopamine

Unilateral intracarotid infusion of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) in baboons produces transient contralateral dystonia lasting 2-3 weeks followed by chronic hemiparkinsonism. We now extend this model to Macaca nemestrina and Macaca fascicularis. MPTP was infused unilaterally into the internal carotid artery of two M. nemestrina and 11 M. fascicularis. Effects were assessed with blinded clinical ratings of dystonia and Parkinsonism; [18F]-6-fluoro-DOPA (FDOPA) positron emission tomography; and postmortem measurements of striatal dopamine content. In two M. nemestrina, MPTP 0.4 mg/kg intracarotid produced acute dystonia within 24 h then chronic Parkinsonism starting 3 weeks later. In three M. fascicularis, MPTP 0.4 mg/kg produced acute dystonia within 3-8 h but two others died from large hemispheric infarcts within 1 day. A much lower dose, MPTP 0.1 mg/kg produced no clinical manifestations (n=1), whereas MPTP 0.25 mg/kg produced consistent transient dystonia and ipsiversive turning within 1-3 days followed by chronic Parkinsonism at 3 weeks (n=5). One week after MPTP, striatal FDOPA uptake decreased an average of 69% in M. nemestrina (0.4 mg/kg); and decreased an average of 70+/-21% in M. fascicularis (0.25 mg/kg). Striatal dopamine was reduced an average 66% in the first day (n=2) during acute dystonia, 98% at 3 days (n=1) and 99%+/-2.3% at 2-4 months (n=5). M. nemestrina had a clinical response similar to baboons whereas M. fascicularis seemed more sensitive to MPTP. These findings extend the model of MPTP-induced transient dystonia followed by chronic hemiparkinsonism to M. nemestrina and M. fascicularis and demonstrate that the early dystonic phase is accompanied by striatal dopamine deficiency.

Pathological Characteristics of Prostate Cancer Detected Through Prostate Specific Antigen Based Screening

PURPOSE

Since the introduction of PSA testing for CaP, there has been an increase in CaP detection. However, it is uncertain to what extent clinically insignificant tumors are being diagnosed and treated. In a large, community based population we determined the pathological characteristics of screening detected cancers.

MATERIALS AND METHODS

From 1989 to 2001, 35,661 men were enrolled in a longitudinal prostate cancer screening study. Data were available on 3,492 of the 3,568 men (98%) diagnosed with CaP during this study period. Radical prostatectomy was performed in 2,254 men (63%). Clinical stage, Gleason score and pathological analysis were recorded and analyzed in the context of preoperative PSA, digital rectal examination findings, PSA velocity and the year of cancer detection.

RESULTS

CaP was detected in 10% of men. Virtually all cases were clinically localized (99.8%) and approximately 70% treated with radical prostatectomy were pathologically organ confined disease. Fewer than 10% of tumors would be considered clinically insignificant based on 2 previously published pathological criteria.

CONCLUSIONS

Compared to the high prevalence of CaP found in autopsy studies there is a lower detection rate using current screening protocols. Although the outcomes are unknown if these tumors had been left untreated, the majority met pathological criteria for significant cancer.

Baseline prostate-specific antigen compared with median prostate-specific antigen for age group as predictor of prostate cancer risk in men younger than 60 years old

OBJECTIVES

Limited data are available concerning the extent to which the initial prostate-specific antigen (PSA) measurement in men younger than age 60 predicts for the risk of prostate cancer (CaP) and how this compares to other known risk factors.

METHODS

From 1991 to 2001, 13,943 men younger than 60 years old participated in a CaP screening study. Men aged 40 to 49 years were eligible for the study if they had a positive family history or African-American heritage, and men older than 50 years were screened without respect to risk factors. The CaP detection rate, PSA velocity, pathologic features, and treatment outcomes were evaluated as a function of the baseline PSA level.

RESULTS

The median PSA level was 0.7 ng/mL for men aged 40 to 49 years and 0.9 ng/mL for men aged 50 to 59. A baseline PSA level between the median and 2.5 ng/mL was associated with a 14.6-fold and 7.6-fold increased risk of CaP in men aged 40 to 49 and 50 to 59 years, respectively. A greater baseline PSA value was also associated with a significantly greater PSA velocity, more aggressive tumor features, a greater biochemical progression rate, and a trend toward a greater cancer-specific mortality rate.

CONCLUSIONS

In men younger than 60, a baseline PSA value between the age-specific median and 2.5 ng/mL was a significant predictor of later CaP and was associated with a significantly greater PSA velocity. A young man's baseline PSA value was a stronger predictor of CaP than family history, race, or suspicious digital rectal examination findings. A greater baseline PSA level was associated with significantly more adverse pathologic features and biochemical progression.

USE OF 2.6 NG/ML PROSTATE SPECIFIC ANTIGEN PROMPT FOR BIOPSY IN MEN OLDER THAN 60 YEARS

PURPOSE

Since the United States Food and Drug Administration approved the prostate specific antigen (PSA) blood test as an aid to early prostate cancer detection, using a cutoff of 4.0 ng/ml in 1994, this cutoff has been widely adopted to recommend prostate biopsy. There has been recent investigation into lowering the PSA prompt for biopsy, especially in men younger than 60 years. We determined how a lower cutoff would perform in men older than 60 years.

MATERIALS AND METHODS

From a prostate cancer screening study we studied 782 consecutive men who underwent prostate biopsy for PSA greater than 2.5 ng/ml or suspicious digital rectal examination. Biopsy results were evaluated as a function of patient age.

RESULTS

Clinical and pathological characteristics of cancers detected in the PSA range 2.6 to 4.0 ng/ml were similar regardless of patient age. Overall PSA between 2.6 and 4.0 ng/ml was associated with a cancer detection rate of 16.2% using a sextant biopsy technique. PSA velocity was similar in men with prostate cancer in all age groups.

CONCLUSIONS

More than 15% of men with PSA 2.6 to 4.0 ng/ml who are 40 years or older have prostate cancer detected with sextant needle biopsies. PSA velocity, tumor stage, Gleason grade and tumor volume were similar in all age groups.

Biopsy of men with PSA level of 2.6 to 4.0 ng/mL associated with favorable pathologic features and PSA progression rate: a preliminary analysis

OBJECTIVES

To compare the pathologic outcomes and prostate-specific antigen (PSA) progression rates of patients who underwent radical prostatectomy because of prostate cancers and whose cancer was detected at a PSA level of 2.6 to 4.0 ng/mL versus those with cancer detected after the PSA level rose to greater than 4.0 ng/mL. Some studies have suggested that clinically significant prostate cancer is detected more frequently in an organ-confined stage with a PSA level between 2.6 and 4.0 ng/mL than with a PSA level greater than 4 ng/mL. However, it is uncertain whether this will affect clinical outcomes.

METHODS

From 1991 to 2001, 20,788 men enrolled in a prostate cancer screening study had an initial PSA level of less than 2.6 ng/mL. Of these patients, 523 had a PSA level that rose to greater than 2.5 ng/mL and had prostate cancer detected. Of the 297 patients who subsequently underwent radical prostatectomy, 223 had a preoperative PSA level of 2.6 to 4.0 ng/mL and 74 had a preoperative PSA level greater than 4.0 ng/mL. The median follow-up was 4 years. The pathologic stage, mean tumor volume, Gleason score, possibly insignificant cancer rate, possibly rapidly progressive cancer rate, and PSA progression rate were compared between the two groups.

RESULTS

The patients with a preoperative PSA level between 2.6 and 4.0 ng/mL had more favorable pathologic outcomes in terms of cancer volume, pathologic stage, and possibly rapidly progressive cancer rate. The possibly insignificant cancer rates were not different between the groups. A trend was noted for patients with a preoperative PSA level between 2.6 and 4.0 ng/mL to have a lower PSA progression rate.

CONCLUSIONS

Biopsy in men with PSA levels between 2.6 and 4.0 ng/mL may detect clinically significant prostate cancer more frequently at an organ-confined stage, with a lower PSA progression rate. Additional study in a larger population with longer follow-up is needed to confirm this trend.

RESULTS OF COMPLIANCE WITH PROSTATE CANCER SCREENING GUIDELINES

PURPOSE

Current guidelines of the American Cancer Society and the National Comprehensive Cancer Network recommend offering annual prostate cancer screening with prostate specific antigen (PSA) and digital rectal examination (DRE) beginning at age 50 (age 45 in high risk men). There are limited data concerning outcomes if all men followed screening guidelines. We report early outcome data on men who entered a prostate cancer screening study, complied with the screening guidelines and were subsequently diagnosed with prostate cancer.

MATERIALS AND METHODS

We reviewed records of men 45 to 59 years old at study entry with a PSA less than 2.6 ng/ml and benign DRE who underwent annual DRE and PSA testing in a screening study between 1991 and 2001. Of 10,174 men with these characteristics, 232 (2.3%) were subsequently diagnosed with prostate cancer. We evaluated PSA, Gleason score, clinical and pathological tumor stage, and treatment outcomes in these men.

RESULTS

Median PSA at diagnosis was 3.1 ng/ml (range 0.4 to 9.6). Gleason scores ranged from 4 to 9. All patients had clinically localized disease. Management included predominantly radical prostatectomy (87%) and radiation therapy (10%). Of cancers in which tumor volume was assessed 13% were considered possibly harmless tumors by previously published criteria and 2% were considered possibly rapidly progressive tumors by criteria we set in this study.

CONCLUSIONS

Prostate cancer screening using some current guidelines results in the detection of cancers that are organ confined in 79% of patients, possibly harmless in less than 15% and possibly rapidly progressive in 2%.

Preoperative PSA and progression-free survival after radical prostatectomy for Stage T1c disease

OBJECTIVES

To examine biochemical progression-free survival (PFS) rates as a function of preoperative prostate-specific antigen (PSA) in patients with clinical Stage T1c prostate cancer treated with radical prostatectomy. Controversy exists about whether performing prostate biopsies for PSA levels in the 2.6 to 4.0 ng/mL range provides a PFS advantage compared with detection at higher PSA ranges.

METHODS

A total of 2804 men with clinical Stage T1c prostate cancer were treated with radical retropubic prostatectomy and monitored prospectively. The study parameters included preoperative PSA level, pathologic tumor stage, and Gleason grade. Patients were grouped into four clinically relevant strata according to their preoperative PSA level: 2.6 to 4.0, 4.1 to 7.0, 7.1 to 10.0, and greater than 10 ng/mL. The primary outcome was the 10-year actuarial biochemical PFS estimate generated using the Kaplan-Meier method. We compared the strata using the log-rank test. Cancer progression rates were compared using the Cochran Armitage test for trend. The chi-square test was used to compare the pathologic parameters among the PSA strata.

RESULTS

Of the men with a preoperative PSA level of 2.6 to 4.0, 4.1 to 7.0, 7.1 to 10.0, and greater than 10.0 ng/mL, 81%, 74%, 72%, and 60%, respectively, had organ-confined disease (P = 0.001) and 23%, 28%, 35%, and 47%, respectively, had a pathologic Gleason grade of 7 or greater (P = 0.001). The corresponding 10-year PFS estimates were 88%, 80%, 76%, and 61% (P = 0.0001, for trend).

CONCLUSIONS

Among men with clinical Stage T1c prostate cancer, those with a PSA level of 2.6 to 4.0 ng/mL had the greatest rate of organ-confined disease, lowest pathologic Gleason grade, and greatest 10-year PFS rate.

Contemporary survival results and the role of radiation therapy in patients with node negative seminal vesicle invasion following radical prostatectomy

PURPOSE

Seminal vesicle invasion (SVI) in a radical prostatectomy (RRP) specimen is associated with a guarded prognosis. We evaluated patients with SVI treated in the pre-prostate specific antigen (PSA) (1983 to 1991) and PSA (1992 to 2003) eras.

MATERIALS AND METHODS

Of patients with prostate cancer treated with RRP from January 1983 through March 2002, 220 with SVI were evaluated, including 67 in the pre-PSA era and 153 in the PSA era. Postoperative PSA greater than 0.2 ng/ml was considered biochemical evidence of cancer progression. Survival rates were compared using Kaplan-Meier estimates to calculate progression-free, cancer specific and all cause survival. Multivariate Cox proportional hazard models were used to correlate variables with disease progression.

RESULTS

The incidence of SVI in the PSA era was lower than in the pre-PSA era (6.0% vs 10.2%, p = 0.001). To date 124 patients (56%) have had evidence of cancer progression. The 4 and 7-year progression-free, cancer specific and all cause survival rates were significantly higher in men with SVI in the PSA era (p = 0.02). PSA at diagnosis, cancerous surgical margins and higher Gleason score were significantly associated with progression. Neither adjuvant nor salvage radiotherapy appeared to confer a significant progression-free survival benefit.

CONCLUSIONS

The incidence of SVI has decreased in the PSA era. Progression-free, cancer specific and all cause survival rates following RRP in patients with SVI have improved in the PSA era. This may reflect earlier detection in this pathological tumor stage and more favorable prognostic factors associated with PSA screening. Adjuvant radiotherapy does not appear to confer any therapeutic benefit. Salvage radiotherapy can lead to durable PSA regressions in a small percent of men, although no long-term survival advantage can be proved.

Delays in cancer detection using 2 and 4-year screening intervals for prostate cancer screening with initial prostate specific antigen less than 2 ng/ml

PURPOSE

The American Urological Association and American Cancer Society advocate annual screening with serum prostate specific antigen (PSA) and digital rectal examination starting at age 50 years in the general population and earlier in men at high risk. Some groups have suggested that screening at 2 or 4-year intervals may be sufficient in men with initial PSA 2 ng/ml or less. We reviewed the records of men enrolled in a PSA and digital rectal examination based prostate cancer screening study to determine the extent to which the diagnosis of cancer would have been delayed using a 2 or 4-year screening interval.

MATERIALS AND METHODS

We evaluated 18,140 volunteers in a prostate cancer screening study in whom PSA was less than 2 ng/ml at initial screening and who were screened at 6-month to 1-year intervals for up to 8 years. We evaluated the cancers detected in these intervals to determine the possible delay in cancer diagnosis that would occur using prolonged screening intervals. We report the overall cancer detection rate, clinical and pathological tumor stage, and Gleason grade of the cancers detected.

RESULTS

Excluding 70 men in whom prostate cancer was detected at initial evaluation 2.0% had prostate cancer detected during the next 8 years (mean 21.6 cancers per 6 months, median 20, range 12 to 33). Using a hypothetical 2-year screening interval cancer detection 62% would have been delayed by 4 to 20 months. Using a hypothetical 4-year screening interval cancer detection would have been delayed in 77% of men by 4 to 44 months. Of the tumors detected 100% were clinically localized, 77% were pathologically organ confined and 29% had a Gleason score of 7 or greater.

CONCLUSIONS

The 2 or 4-year PSA screening interval in men with initial serum PSA less than 2 ng/ml would result in substantial delays in prostate cancer detection. To our knowledge the extent to which these delays would affect treatment outcomes is undetermined.

Accuracy of prostate weight estimation by digital rectal examination versus transrectal ultrasonography

PURPOSE

The ability to estimate prostate weight is useful. Two commonly used methods for estimating prostate weight are digital rectal examination (DRE) and transrectal ultrasonography (TRUS). We evaluated the relative accuracy of these weight estimates by comparing them to prostate weight following radical retropubic prostatectomy (RRP).

MATERIALS AND METHODS

Between 1989 and 2001 more than 36,000 community men participated in a large prostate cancer screening study. Of these men 2,238 underwent RRP. In this subset we examined the correlation between documented preoperative DRE and TRUS estimates of prostate weight with actual gland weight.

RESULTS

DRE estimates of prostate weight by multiple examiners correlated poorly with RRP specimen weight (r = 0.2743). However, TRUS estimates correlated moderately well (r = 0.6493). TRUS provided more accurate estimates of prostate weight for smaller glands, although it generally underestimated gland weight compared to the weight of the surgical specimen.

CONCLUSIONS

In a large, community based prostate cancer screening study prostate weight estimated by DRE was shown to correlate poorly with actual prostate weight. Compared with DRE, TRUS provides a better estimate of prostate weight. In addition, TRUS measurements were more accurate in smaller prostate glands.

POTENCY, CONTINENCE AND COMPLICATIONS IN 3,477 CONSECUTIVE RADICAL RETROPUBIC PROSTATECTOMIES

PURPOSE

We report results in a series of 3,477 consecutive patients treated with anatomical nerve sparing radical retropubic prostatectomy (RRP) in terms of recovery of erectile function, urinary continence and postoperative complications.

MATERIALS AND METHODS

From May 1983 through February 2003, 1 surgeon (WJC) performed anatomical RRP using a unilateral or bilateral nerve sparing modification when possible. Urinary continence and recovery of erections were evaluated in men with a minimum followup of 18 months. Excluded from potency analysis were men who were not reliably potent before surgery, those who did not undergo a nerve sparing procedure and those who received postoperative adjuvant radiotherapy or hormonal therapy within 18 months of surgery. Other postoperative complications in this patient population were also evaluated.

RESULTS

Erections sufficient for intercourse occurred in 76% of preoperatively potent men treated with bilateral (1,770) and 53% of men treated with unilateral or partial nerve sparing (64) surgery. Adequate erectile function was more common following bilateral than unilateral nerve sparing surgery in men younger than 70 years old (78% versus 53%, p = 0.001) compared with those 70 years old or older (52% versus 56%, p = 0.6). Recovery of urinary continence occurred in 93% of all men and was associated with younger age (p = 0.001) but not nerve sparing surgery, tumor stage, prostate specific antigen (PSA), Gleason grade or number of prior prostatectomies performed by the surgeon. Postoperative complications occurred in 320 (9%) of patients and were associated with older age (p <0.0001), nonnerve sparing surgery (p = 0.001), PSA era (p <0.0001) and surgeon experience. Complications were not significantly correlated with clinical stage, pathological stage, preoperative PSA or Gleason grade. There was no perioperative mortality.

CONCLUSIONS

Nerve sparing RRP can be performed with favorable potency and urinary continence. Better results are achieved in younger men. Other complications are reduced with increasing surgeon experience.

ASSOCIATION OF HEMOSPERMIA WITH PROSTATE CANCER

PURPOSE

Hemospermia is uncommon clinical condition that usually follows a benign course. The association between hemospermia and prostate cancer has been reported but to our knowledge not thoroughly investigated. We studied the incidence of hemospermia and the association between prostate cancer and hemospermia in a large prostate cancer screening population.

MATERIALS AND METHODS

Between 1991 and 2001, 26,126 ambulatory men 50 years or older (40 years or older with a family history of prostate cancer or black race) underwent a community based prostate cancer screening study using serum prostate specific antigen (PSA) and digital rectal examination (DRE). PSA measurement and DRE were repeated at 6-month or 1-year intervals depending on PSA for the remainder of the study. Men underwent prostate biopsy due to increased serum PSA (greater than 4.0 ng/ml until May 1995 or greater than 2.5 ng/ml after May 1995) or suspicious DRE. Men with a history of prostate cancer were excluded from study. Men completed a questionnaire, including information about hemospermia, at each screening visit. Hemospermia information from the initial questionnaire was analyzed. The relative risk of prostate cancer diagnosis in the overall prostate cancer screening population and the cohort with hemospermia was determined. Detailed prostate cancer characteristics were evaluated in those who had hemospermia and underwent radical prostatectomy. We used a multivariate logistic regression model to test the independent significance of hemospermia after adjusting for other known predictors of prostate cancer detection.

RESULTS

Prostate cancer was detected in 1,708 of the 26,126 men (6.5%) who underwent prostate cancer screening. Prostate cancer was diagnosed in 19 of the 139 men (13.7%) who reported hemospermia upon entering the prostate cancer screening study. The median age of the 139 men was 61 years (range 40 to 89). Ten of the 13 men who underwent radical retropubic prostatectomy had stage pT2 disease, while 3 had stage pT3 disease. In the logistic regression model hemospermia was a significant predictor of prostate cancer diagnosis after adjusting for age, PSA and DRE results (OR 1.73, p = 0.054).

CONCLUSIONS

Hemospermia is rare (0.5%) in a prostate cancer screening population. When a man presents with hemospermia, prostate cancer screening should be vigilantly performed since hemospermia is associated with an increased risk of prostate cancer.

Cancer progression and survival rates following anatomical radical retropubic prostatectomy in 3,478 consecutive patients: long-term results

PURPOSE

We updated a long-term cancer control outcome in a large anatomical radical retropubic prostatectomy (RRP) series. We also evaluated the perioperative parameters that predict cancer specific outcomes following surgery.

MATERIALS AND METHODS

From May 1983 to February 2003, 1 surgeon (WJC) performed RRP in 3,478 consecutive men. Patients were followed with semiannual serum prostate specific antigen (PSA) tests and annual digital rectal examinations. We used Kaplan-Meier product limit estimates to calculate actuarial 10-year probabilities of biochemical progression-free survival, cancer specific survival and overall survival. Multivariate Cox proportional hazards models were used to determine independent perioperative predictors of cancer progression.

RESULTS

At a mean followup of 65 months (range 0 to 233) actuarial 10-year biochemical progression-free, cancer specific and overall survival probabilities were 68%, 97% and 83%, respectively. On multivariate analysis biochemical progression-free survival probability was significantly associated with preoperative PSA, clinical tumor stage, Gleason sum, pathological stage and treatment era. Cancer specific survival and overall survival rates were also significantly associated with clinicopathological parameters.

CONCLUSIONS

RRP can be performed with excellent survival outcomes. Favorable clinicopathological parameters and treatment in the PSA era are associated with improved cancer control.

Percent carcinoma in prostatectomy specimen is associated with risk of recurrence after radical prostatectomy in patients with pathologically organ confined prostate cancer

PURPOSE

We evaluated tumor size, measured as the percent of the prostate involved by cancer, as a predictor of tumor recurrence after radical prostatectomy in patients with pathologically organ confined prostate cancer.

MATERIALS AND METHODS

One of us (WJC) performed radical retropubic prostatectomy in 1,850 men who had pathologically organ confined prostate cancer with tumor size recorded between January 1988 and February 2003. The percent of prostate tissue involved by carcinoma in the radical prostatectomy specimen was estimated by visual inspection. We compared clinicopathological characteristics in patients who did and did not have tumor recurrence and stratified them by percent of tumor in the prostatectomy specimen. We also evaluated the relationship between percent of cancer and biochemical evidence of cancer recurrence.

RESULTS

Patients who had recurrence were slightly older (mean age 62 vs 60 years, p = 0.004), and had higher mean preoperative prostate specific antigen (8.6 vs 6.3 ng/ml, p <0.0001) and a higher proportion of poorly differentiated tumors (Gleason grades 8 to 10) (7% vs 1%, p = 0.001). The mean percent of cancer was higher in men with recurrence (11% vs 7%, p <0.0001). Men with 10% or greater of the gland involved by cancer had a 10% recurrence rate compared with a 5% rate in men in whom cancer involved less than 10% of the gland (p = 0.001). The 5-year recurrence-free survival rate was 94%, 91% and 82% in patients with less than 10%, 10% to 20% and greater than 20% of the gland involved. The multivariate Cox model indicated that the percent of cancer involvement of the prostate provides unique predictive information about the risk of cancer recurrence (p = 0.0001). The estimated 5-year recurrence-free survival rate based on the Cox model indicated that patients with greater than 20% of the gland involved by tumor, clinical stage T2/T3 and Gleason sum >/=7 were at substantial risk of cancer recurrence.

CONCLUSIONS

Tumor size measured as the percent of cancer is an independent predictor of cancer recurrence after radical prostatectomy in patients with pathologically organ confined prostate cancer.

RELATIONSHIP BETWEEN INITIAL PROSTATE SPECIFIC ANTIGEN LEVEL AND SUBSEQUENT PROSTATE CANCER DETECTION IN A LONGITUDINAL SCREENING STUDY

PURPOSE

Previous studies of archived blood samples from nonscreened populations have shown an association between the prostate specific antigen (PSA) and the subsequent detection of prostate cancer. In the current study we evaluated the relationship between the initial screening PSA and the subsequent risk of prostate cancer detected in a prospective, longitudinal screening study. We also examined the relationship between initial PSA and the clinicopathological features of the cancers detected.

MATERIALS AND METHODS

Between May 1991 and November 2001 we enrolled 26,111 volunteers in our PSA and digital rectal examination based prostate cancer screening study. The men were followed biannually or annually depending on the results of previous screening tests. The chi-square and Kruskal-Wallis tests were used to compare the clinical stage, pathological stage and Gleason score of subsequently detected prostate cancers as well as the time to cancer detection in different initial screening PSA strata.

RESULTS

The initial screening PSA stratum was strongly associated with the subsequent detection of prostate cancer as well as the clinicopathological stage and grade of the cancers detected.

CONCLUSIONS

Even in the lower PSA ranges initial screening serum PSA can help identify men at increased risk for subsequent prostate cancer detected in a longitudinal screening study.

Clinical Value of Longitudinal Free-to-Total Prostate Specific Antigen Ratio Slope to Diagnosis of Prostate Cancer

PURPOSE

Free and total serum prostate specific antigen (PSA) levels are frequently used for early prostate cancer detection in men with a total PSA in the 2.6 to 10 ng/ml range. Results from a longitudinal study suggested that the free-to-total PSA ratio (F/T PSA), declining the decade before prostate cancer diagnosis, is the earliest serum marker predicting a subsequent diagnosis of prostate cancer. Other than this study, there are limited data on the predictive value of longitudinal F/T PSA measurements for subsequent cancer. To evaluate the clinical importance of a decreasing F/T PSA, we compared longitudinal F/T PSA in volunteers in a prostate cancer screening study.

MATERIALS AND METHODS

We evaluated 657 volunteers in a screening study with a total PSA of 2.6 to 10 ng/ml but whose initial biopsies were either negative for cancer or were waived. To obtain meaningful F/T PSA slopes, the patients have been followed with at least 3 F/T PSA levels measured for 3 or greater years (mean 3.5, median 3.5, range 3 to 5.3). Of these men 22 subsequently were diagnosed with prostate cancer. We calculated the F/T PSA slope as the last F/T PSA minus the first F/T PSA divided by the interval between the measurements. The F/T PSA slopes of the patients with and without cancer were compared using chi-square analysis.

RESULTS

Mean F/T PSA slope for the patients with cancer was -0.06 (median -0.03, range -0.63 to 0.22) compared to mean slope of -0.02 (median -0.01, range -0.57 to 0.69) for patients without cancer (p = 0.21). Of the patients with cancer 61% had a negative slope compared with 54% of patients without cancer (p = 0.59). The positive predictive value of a negative F/T PSA slope for subsequent cancer detection to date is only 4%.

CONCLUSIONS

A decreasing F/T PSA during a 3 to 5-year interval has little value in predicting subsequent diagnosis of prostate cancer. Further followup of a larger number of patients will be required to determine the value of longitudinal F/T PSA measurements in early prostate cancer detection.

Overwork weakness in Charcot-Marie-Tooth disease

OBJECTIVE

To determine the incidence of overwork weakness in Charcot-Marie-Tooth disease (CMT).

DESIGN

Prospective survey.

SETTING

Rehabilitation department for CMT in an Italian tertiary care hospital.

PARTICIPANTS

A total of 106 outpatients with CMT, selected for absence of other causes of weakness (age range, 11-69y), and 48 healthy volunteers (controls).

INTERVENTIONS

The strength of 2 intrinsic hand muscles (abductor pollicis brevis [APB], first dorsal interosseous) in the dominant and nondominant hands was graded by using manual muscle testing and a modified Medical Research Council (MRC) Scale.

MAIN OUTCOME MEASURES

The side of the stronger muscle and the difference in strength between the nondominant and dominant muscles.

RESULTS

Muscles were stronger on the nondominant side in 65.57% of patients versus 1.04% of controls, and on the dominant side in .94% of patients versus 84.38% controls. The difference in strength for first dorsal interosseous was .51 in patients and -.32 in controls (P>.01). The difference in strength for APB was .65 in patients and -.35 in controls (P>.01).

CONCLUSIONS

CMT muscles in the dominant hand are weaker than in the nondominant hand. This may be the result of overwork weakness.

Screening for prostate cancer in high risk populations

PURPOSE

Black men and men with a family history of prostate cancer are at higher risk for this disease and may have an earlier age of onset. Consequently, screening at a younger age has been recommended for high risk men, however, there are limited data on actual screening results in young, high risk populations.

MATERIALS AND METHODS

In men 50 years old or older we compared screening results in 1,224 black men, 1,227 men with a positive family history and 63 men who were both with those of 15,964 nonblack men with no known family history. In high risk men in their forties we also evaluated the percent with abnormal screening tests, the positive predictive value of screening tests, cancer detection rates and the prognostic features of tumors detected.

RESULTS

In men 50 years old or older prostate cancer detection rates were 6.4% for controls compared with 10.3%, 10.5% and 17.5%, respectively, for the high risk groups. Among high risk men screened in their forties 8% had suspicious screening tests and approximately 55% who underwent a biopsy had cancer detected. Of tumors detected 80% were organ confined and all but 1 were of moderate Gleason grade 5 years old or older. Only 1 tumor (7%) fulfilled the published criteria for a possibly harmless cancer.

CONCLUSIONS

Black men and men with a family history of prostate cancer are at a 75% to 80% higher risk for prostate cancer. On initial screening of high risk men in their fourth decade only 8% have positive screening tests; however, approximately 55% of these men have tumors, most of which are medically important with favorable prognostic features.

Screening for prostate cancer in high risk populations

PURPOSE

Black men and men with a family history of prostate cancer are at higher risk for this disease and may have an earlier age of onset. Consequently, screening at a younger age has been recommended for high risk men, however, there are limited data on actual screening results in young, high risk populations.

MATERIALS AND METHODS

In men 50 years old or older we compared screening results in 1,224 black men, 1,227 men with a positive family history and 63 men who were both with those of 15,964 nonblack men with no known family history. In high risk men in their forties we also evaluated the percent with abnormal screening tests, the positive predictive value of screening tests, cancer detection rates and the prognostic features of tumors detected.

RESULTS

In men 50 years old or older prostate cancer detection rates were 6.4% for controls compared with 10.3%, 10.5% and 17.5%, respectively, for the high risk groups. Among high risk men screened in their forties 8% had suspicious screening tests and approximately 55% who underwent a biopsy had cancer detected. Of tumors detected 80% were organ confined and all but 1 were of moderate Gleason grade 5 years old or older. Only 1 tumor (7%) fulfilled the published criteria for a possibly harmless cancer.

CONCLUSIONS

Black men and men with a family history of prostate cancer are at a 75% to 80% higher risk for prostate cancer. On initial screening of high risk men in their fourth decade only 8% have positive screening tests; however, approximately 55% of these men have tumors, most of which are medically important with favorable prognostic features.

Robustness of free prostate specific antigen measurements to reduce unnecessary biopsies in the 2.6 to 4.0 ng./ml. range

PURPOSE

Prostate specific antigen (PSA) cutoffs lower than 4.0 ng./ml. are being evaluated more frequently but lower PSA cutoffs increase the number of prostatic biopsies. PSA exists in several forms free and complexed to proteins. Percent free PSA is lower in men with prostate cancer. Accordingly, free PSA and complexed PSA have been used to distinguish between cancer and benign disease in the diagnostic gray zone of 4 to 10 ng./ml. to eliminate unnecessary biopsies. There are limited data on the robustness of free PSA measurements in the 2.6 to 4.0 ng./ml. total PSA range.

MATERIALS AND METHODS

We evaluated percent free PSA measurements to discriminate between cancer and benign conditions in 965 consecutive volunteers in a prostate cancer screening study who underwent prostatic biopsy for a PSA of 2.6 to 4.0 ng./ml. and had benign digital rectal examination.

RESULTS

Overall 25% of men had cancer detected. A 25% free PSA cutoff detected 85% of cancers and avoided 19% of negative (cancer-free) biopsies, while a 30% free PSA cutoff detected 93% of cancers and avoided only 9% of negative biopsies. Of those men who underwent radical prostatectomy 132 (80%) had pathologically organ confined tumors. Only 5% of these tumors fulfilled the published pathological criteria for possibly clinically unimportant tumors.

CONCLUSIONS

Percent free PSA provides risk assessment but does not eliminate many unnecessary prostatic biopsies while maintaining a high sensitivity in the narrow total PSA range of 2.6 to 4.0 ng./ml.

Robustness of free prostate specific antigen measurements to reduce unnecessary biopsies in the 2.6 to 4.0 ng./ml. range

PURPOSE

Prostate specific antigen (PSA) cutoffs lower than 4.0 ng./ml. are being evaluated more frequently but lower PSA cutoffs increase the number of prostatic biopsies. PSA exists in several forms free and complexed to proteins. Percent free PSA is lower in men with prostate cancer. Accordingly, free PSA and complexed PSA have been used to distinguish between cancer and benign disease in the diagnostic gray zone of 4 to 10 ng./ml. to eliminate unnecessary biopsies. There are limited data on the robustness of free PSA measurements in the 2.6 to 4.0 ng./ml. total PSA range.

MATERIALS AND METHODS

We evaluated percent free PSA measurements to discriminate between cancer and benign conditions in 965 consecutive volunteers in a prostate cancer screening study who underwent prostatic biopsy for a PSA of 2.6 to 4.0 ng./ml. and had benign digital rectal examination.

RESULTS

Overall 25% of men had cancer detected. A 25% free PSA cutoff detected 85% of cancers and avoided 19% of negative (cancer-free) biopsies, while a 30% free PSA cutoff detected 93% of cancers and avoided only 9% of negative biopsies. Of those men who underwent radical prostatectomy 132 (80%) had pathologically organ confined tumors. Only 5% of these tumors fulfilled the published pathological criteria for possibly clinically unimportant tumors.

CONCLUSIONS

Percent free PSA provides risk assessment but does not eliminate many unnecessary prostatic biopsies while maintaining a high sensitivity in the narrow total PSA range of 2.6 to 4.0 ng./ml.

Serial biopsy results in prostate cancer screening study

PURPOSE

We evaluated prostate biopsy results in men with elevated prostate specific antigen (PSA) levels and/or suspicious digital rectal examination whose initial biopsies did not reveal cancer.

MATERIALS AND METHODS

A total of 2,526 volunteers 40 years old or older underwent 1 or more prostate biopsies for serum PSA concentrations greater than 4.0 ng./ml. (before May 1995) or greater than 2.5 ng./ml. (after May 1995), or digital rectal examination suspicious of cancer. We evaluated compliance with the biopsy recommendation and the cancer detection rate with regard to digital rectal examination results and increasing PSA levels.

RESULTS

Of the men who underwent up to 10 biopsy procedures the serial cancer detection rates were 29%, 17%, 14%, 11%, 9% and 7%, respectively, on biopsy procedures 1 through 6. No significant difference in the yield of cancer on serial biopsies was observed between the groups using the greater than 4.0 ng./ml. and greater than 2.5 ng./ml. cutoff. There was a trend for more cancers detected through serial screening to be organ confined compared with those detected on initial screening (78% versus 69%, p = 0.05). Also, more cancers detected using the greater than 2.5 ng./ml. cutoff were organ confined (80% versus 66%, p = 0.004). Only approximately 1% of the cancers fulfilled the published criteria for clinically insignificant tumors.

CONCLUSIONS

Nearly a quarter of prostate cancers detected in this screening study were missed by the initial biopsy. Of the 962 prostate cancers detected 77% were detected with 1, 91% with 2, 97% with 3 and 99% with 4 biopsy procedures. Serial biopsies detect more organ confined cancers without over detecting clinically unimportant tumors. Future studies are needed to determine whether obtaining more biopsy cores initially would provide earlier prostate cancer detection and avoid unnecessary repeat biopsies.

Serial biopsy results in prostate cancer screening study

PURPOSE

We evaluated prostate biopsy results in men with elevated prostate specific antigen (PSA) levels and/or suspicious digital rectal examination whose initial biopsies did not reveal cancer.

MATERIALS AND METHODS

A total of 2,526 volunteers 40 years old or older underwent 1 or more prostate biopsies for serum PSA concentrations greater than 4.0 ng./ml. (before May 1995) or greater than 2.5 ng./ml. (after May 1995), or digital rectal examination suspicious of cancer. We evaluated compliance with the biopsy recommendation and the cancer detection rate with regard to digital rectal examination results and increasing PSA levels.

RESULTS

Of the men who underwent up to 10 biopsy procedures the serial cancer detection rates were 29%, 17%, 14%, 11%, 9% and 7%, respectively, on biopsy procedures 1 through 6. No significant difference in the yield of cancer on serial biopsies was observed between the groups using the greater than 4.0 ng./ml. and greater than 2.5 ng./ml. cutoff. There was a trend for more cancers detected through serial screening to be organ confined compared with those detected on initial screening (78% versus 69%, p = 0.05). Also, more cancers detected using the greater than 2.5 ng./ml. cutoff were organ confined (80% versus 66%, p = 0.004). Only approximately 1% of the cancers fulfilled the published criteria for clinically insignificant tumors.

CONCLUSIONS

Nearly a quarter of prostate cancers detected in this screening study were missed by the initial biopsy. Of the 962 prostate cancers detected 77% were detected with 1, 91% with 2, 97% with 3 and 99% with 4 biopsy procedures. Serial biopsies detect more organ confined cancers without over detecting clinically unimportant tumors. Future studies are needed to determine whether obtaining more biopsy cores initially would provide earlier prostate cancer detection and avoid unnecessary repeat biopsies.