Objectives
To evaluate the effects of testosterone‐replacement therapy (TRT) on prostate health indicators in hypogonadal men, including rates of prostate cancer diagnoses, changes in ...prostate‐specific antigen (PSA) levels and lower urinary tract symptoms (LUTS) over time.
Patients and Methods
The Registry of Hypogonadism in Men (RHYME) is a multi‐national patient registry of treated and untreated, newly‐diagnosed hypogonadal men (n = 999). Follow‐up assessments were performed at 3–6, 12, 24, and 36 months. Baseline and follow‐up data collection included medical history, physical examination, blood sampling, and patient questionnaires. Prostate biopsies underwent blinded independent adjudication for the presence and severity of prostate cancer; PSA and testosterone levels were measured via local and central laboratory assays; and LUTS severity was assessed via the International Prostate Symptom Score (IPSS). Incidence rates per 100 000 person‐years were calculated. Longitudinal mixed models were used to assess effects of testosterone on PSA levels and IPSS.
Results
Of the 999 men with clinically diagnosed hypogonadism (HG), 750 (75%) initiated TRT, contributing 23 900 person‐months of exposure. The mean testosterone levels increased from 8.3 to 15.4 nmol/L in treated men, compared to only a slight increase from 9.4 to 11.3 nmol/L in untreated men. In all, 55 biopsies were performed for suspected prostate cancer, and 12 non‐cancer related biopsies were performed for other reasons. Overall, the proportion of positive biopsies was nearly identical in men on TRT (37.5%) compared to those not on TRT (37.0%) over the course of the study. There were no differences in PSA levels, total IPSS, or the IPSS obstructive sub‐scale score by TRT status. Lower IPSS irritative sub‐scale scores were reported in treated compared to untreated men.
Conclusions
Results support prostate safety of TRT in newly diagnosed men with HG.
The European Randomized study of Screening for Prostate Cancer (ERSPC) has previously demonstrated that prostate-specific antigen (PSA) screening decreases prostate cancer (PCa) mortality.
To ...determine whether PSA screening decreases PCa mortality for up to 16yr and to assess results following adjustment for nonparticipation and the number of screening rounds attended.
This multicentre population-based randomised screening trial was conducted in eight European countries. Report includes 182160 men, followed up until 2014 (maximum of 16yr), with a predefined core age group of 162389 men (55–69yr), selected from population registry.
The outcome was PCa mortality, also assessed with adjustment for nonparticipation and the number of screening rounds attended.
The rate ratio of PCa mortality was 0.80 (95% confidence interval CI 0.72–0.89, p<0.001) at 16yr. The difference in absolute PCa mortality increased from 0.14% at 13yr to 0.18% at 16yr. The number of men needed to be invited for screening to prevent one PCa death was 570 at 16yr compared with 742 at 13yr. The number needed to diagnose was reduced to 18 from 26 at 13yr. Men with PCa detected during the first round had a higher prevalence of PSA >20ng/ml (9.9% compared with 4.1% in the second round, p<0.001) and higher PCa mortality (hazard ratio=1.86, p<0.001) than those detected subsequently.
Findings corroborate earlier results that PSA screening significantly reduces PCa mortality, showing larger absolute benefit with longer follow-up and a reduction in excess incidence. Repeated screening may be important to reduce PCa mortality on a population level.
In this report, we looked at the outcomes from prostate cancer in a large European population. We found that repeated screening reduces the risk of dying from prostate cancer.
This European Randomized study of Screening for Prostate Cancer trial follow-up reports that repeated screening reduces the risk of dying from prostate cancer for up to 16yr.
Abstract Context The number and location of biopsy cores and the interpretation of prostate biopsy in different clinical settings remain the subjects of continuing debate. Objective Our aim was to ...review the current evidence regarding the performance and interpretation of initial, repeat, and saturation prostatic biopsy. Evidence acquisition A comprehensive Medline search was performed using the Medical Subject Heading search terms prostate biopsy, prostate cancer, detection, transrectal ultrasound (TRUS) , nomogram, and diagnosis . Results were restricted to the English language, with preference given to those published within the last 3 yr. Evidence synthesis At initial biopsy, a minimum of 10 but not >18 systematic cores are recommended, with 14–18 cores in glands ≥50 cm3 . Biopsies should be directed laterally, and transition zone (TZ) cores are not recommended in the initial biopsy setting. Further biopsy sets, either as an extended repeat or as a saturation biopsy (≥20 cores) including the TZ, are warranted in young and fit men with a persistent suspicion of prostate cancer. An immediate repeat biopsy is not indicated for prior high-grade prostatic intraepithelial neoplasia diagnosis given an adequate extended initial biopsy. Conversely, biopsies with atypical glands that are suspicious but not diagnostic of cancer should be repeated within 3–6 mo. Overall recommendations for further biopsy sets (a third set or more) cannot be made. Transrectal ultrasound–guided systematic biopsies represent the standard-of-care method of prostate sampling. However, transperineal biopsies are an up-to-standard alternative. Conclusions The optimal prostatic biopsy regimen should be based on the individualized clinical setting of the patient and should follow the minimum standard requirements reported in this paper.
Abstract Background Screening for prostate cancer (PC) is controversial due to uncertainties about its efficiency. Objective We aimed to develop strategies to reduce the number of unnecessary ...biopsies while still detecting most clinically important PC cases. Design, setting, and participants In 1850 men initially screened and biopsied (prostate-specific antigen PSA value ≥3.0 ng/ml) in the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer, we calculated both the probability of having a positive lateralized sextant biopsy P(biop+) and the probability of having an indolent cancer P(ind) if PC was detected at biopsy ( n = 541). Analyses of repeat screening included 225 cancers in 1201 men. Interventions The P(biop+) was based on applying a logistic regression model that included ultrasound volume, digital rectal exam, and transrectal ultrasound in addition to the PSA value. The P(ind) was based on a recently validated nomogram. Measurements and limitations At initial screening the fraction of positive biopsies was 29% (541 of 1850). Applying an additional P(biop+) cut-off of 12.5% implied that 613 of the 1850 men (33%) would not have been biopsied. This would result in an increase in the positive predictive value (PPV) to 38% (468 of 1237). At repeat screening a similar P(biop+) cut-off would result in an increase in the PPV from 19% (225 of 1201) to 25% (188 of 760). Thirteen percent of PC cases would not have been diagnosed, of which 70% (initial screening) and 81% (repeat screening) could be considered as potentially indolent. None of the deadly PC cases would have been missed. A PSA cut-off of ≥4.0 ng/ml resulted in similar numbers of biopsied cases saved but considerably higher numbers of missed diagnoses. Conclusions An individualized screening algorithm using other available prebiopsy information in addition to PSA level can result in a considerable reduction of unnecessary biopsies. Very few important PC cases, for which diagnosis at a subsequent screening visit might be too late for treatment with curative intent, would be missed.
Risk-Based Prostate Cancer Screening Zhu, Xiaoye; Albertsen, Peter C; Andriole, Gerald L ...
European urology,
04/2012, Letnik:
61, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Abstract Context Widespread mass screening of prostate cancer (PCa) is not recommended because the balance between benefits and harms is still not well established. The achieved mortality reduction ...comes with considerable harm such as unnecessary biopsies, overdiagnoses, and overtreatment. Therefore, patient stratification with regard to PCa risk and aggressiveness is necessary to identify those men who are at risk and may actually benefit from early detection. Objective This review critically examines the current evidence regarding risk-based PCa screening. Evidence acquisition A search of the literature was performed using the Medline database. Further studies were selected based on manual searches of reference lists and review articles. Evidence synthesis Prostate-specific antigen (PSA) has been shown to be the single most significant predictive factor for identifying men at increased risk of developing PCa. Especially in men with no additional risk factors, PSA alone provides an appropriate marker up to 30 yr into the future. After assessment of an early PSA test, the screening frequency may be determined based on individualized risk. A limited list of additional factors such as age, comorbidity, prostate volume, family history, ethnicity, and previous biopsy status have been identified to modify risk and are important for consideration in routine practice. In men with a known PSA, risk calculators may hold the promise of identifying those who are at increased risk of having PCa and are therefore candidates for biopsy. Conclusions PSA testing may serve as the foundation for a more risk-based assessment. However, the decision to undergo early PSA testing should be a shared one between the patient and his physician based on information balancing its advantages and disadvantages.
Abstract This review is triggered by recent developments that offer new explanations for the mechanism of progression of prostate cancer to androgen independence. Established and hypothetical ...mechanisms, which have been described in the past, are put into perspective with recent progress in the field. A total of seven mechanisms can be identified that relate to progression to androgen independence. Five of those are dependent on the androgen receptor, which is present or over-expressed in androgen-independent prostate cancer tissue. Probably due to selective pressure, AIPC cells have the capability to escape from the effect of castration and antiandrogens; exclusion of the androgen receptor activity by inhibition of dimerisation or inhibition of DNA binding seem to be the logical next steps. Although androgen levels and androgen synthesis are suppressed in prostatic tissues during the phase of response to endocrine treatment, androgen levels and, specifically, 5-α-dihydrotestosterone (DHT) were elevated in tissues derived from metastases of AIPC. In addition, all enzymes needed to synthesise androgens from the level of pregnenolone on are present or over-expressed in such tissue. This offers new potential for treatment.
We have developed a statistical prediction model for prostate cancer based on four kallikrein markers in blood: total, free, and intact prostate-specific antigen (PSA), and kallikrein-related ...peptidase 2 (hK2). Although this model accurately predicts the result of biopsy in unscreened men, its properties for men with a history of PSA screening have not been fully characterized.
A total of 1,501 previously screened men with elevated PSA underwent initial biopsy during rounds 2 and 3 of the European Randomized Study of Screening for Prostate Cancer, Rotterdam, with 388 cancers diagnosed. Biomarker levels were measured in serum samples taken before biopsy. The prediction model developed on the unscreened cohort was then applied and predictions compared with biopsy outcome.
The previously developed four-kallikrein prediction model had much higher predictive accuracy than PSA and age alone (area under the curve of 0.711 versus 0.585, and 0.713 versus 0.557 with and without digital rectal exam, respectively; both P < 0.001). Similar statistically significant enhancements were seen for high-grade cancer. Applying the model with a cutoff of 20% cancer risk as the criterion for biopsy would reduce the biopsy rate by 362 for every 1,000 men with elevated PSA. Although diagnosis would be delayed for 47 cancers, these would be predominately low-stage and low-grade (83% Gleason 6 T(1c)).
A panel of four kallikreins can help predict the result of initial biopsy in previously screened men with elevated PSA. Use of a statistical model based on the panel would substantially decrease rates of unnecessary biopsy.
Study Type – Therapy (prospective cohort) Level of Evidence 2b
OBJECTIVE
To evaluate the short‐term outcomes of the prospective international Prostate Cancer Research International: Active ...Surveillance (‘PRIAS’) study (Dutch Trial Register NTR1718), as active surveillance (AS) for early prostate cancer might provide a partial solution to the current overtreatment dilemma in this disease.
PATIENTS AND METHODS
The first 500 (of >950) participants with asymptomatic T1c/T2 prostate cancer, with a prostate‐specific antigen (PSA) level of ≤10.0 ng/mL, a PSA density of <0.2 ng/mL/mL, a Gleason score of ≤3 + 3 = 6, and one or two positive biopsy cores, were analysed. The follow‐up protocol consisted of frequent PSA measurements, digital rectal examinations, and standard repeat biopsies (the first after 1 year). The primary outcome is survival free of active therapy; the secondary endpoints are reasons for stopping AS, findings in 1‐year repeat biopsies, and outcomes after radical prostatectomy (RP).
RESULTS
Patients were included between December 2006 and July 2008. The median (25–75th percentile) follow‐up after diagnosis was 1.02 (0.6–1.5) years. The 2‐year survival rate free from active therapy was 73%. Of the 82 men who changed to active therapy during the follow‐up, 68 (83%) did so based on the protocol. Of the 261 repeat biopsies available for analysis, 90 (34%) showed no cancer, while 57 (22%) showed a Gleason score of >6 or more than two positive biopsy cores. There was a relatively unfavourable PSA doubling time of 0–10 years in 53% (102/194) and 62% (33/53) of men with favourable and unfavourable re‐biopsy results, respectively. After RP, four of 24 (17%) men had T3 disease and 12 (50%) had a Gleason score of >6.
CONCLUSION
AS seems feasible, but mortality outcomes are unknown. A strict follow‐up protocol including standard 1‐year repeat biopsies resulted in a quarter of men stopping AS after 2 years.
Abstract Background Large randomized screening trials provide an estimation of the effect of screening at a population-based level. The effect of screening for individuals, however, is diluted by ...nonattendance and contamination in the trial arms. Objective To determine the prostate cancer (PCa) mortality reduction from screening after adjustment for nonattendance and contamination. Design, setting, and participants A total of 34 833 men in the core age group, 55–69 yr, were randomized to a screening or control arm in the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer (ERSPC). Prostate-specific antigen (PSA) testing was offered to all men in the screening arm at 4-yr intervals. A prostate biopsy was offered to men with an elevated PSA. The primary end point was PCa-specific mortality. Outcome measurements and statistical analysis Nonattendance was defined as nonparticipation in the screening arm. Contamination in the control arm was defined as receiving asymptomatic PSA testing or a prostate biopsy in the absence of symptoms. Relative risks (RRs) were calculated with an intention to screen (ITS) analysis and after correction for nonattendance and contamination using a method that preserves the benefits obtained by randomization. Results and limitations The ITS analysis resulted in an RR of 0.68 (95% confidence interval CI, 0.53–0.89) in favor of screening at a median follow-up of 13 yr. Correction for both nonattendance and contamination resulted in an RR of 0.49 (95% CI, 0.27–0.87) in favor of screening. Conclusions PCa screening as conducted in the Rotterdam section of the ERSPC can reduce the risk of dying from PCa up to 51% for an individual man choosing to be screened repeatedly compared with a man who was not screened. This benefit of screening should be balanced against the harms of overdiagnosis and subsequent overtreatment. Trial registration ISRCTN49127736.
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