Stage Migration Of Prostate Cancer Research Articles

Prostate-specific membrane antigen-PET/CT may result in stage migration in prostate cancer: performances, quantitative analysis, and potential criticism in the clinical practice.

The early detection of prostate cancer (PCa) metastatic disease with PET imaging leads to stage migration and change of disease management. We aimed to assess the impact on clinical management deriving from prostate-specific membrane antigen (PSMA) imaging with a digital PET/CT during the routine application in the staging and restaging process of PCa. Eighty consecutive PCa patients underwent 18F-PSMA-1007. Digital PET/CT were retrospectively evaluated and discussed with oncologists to evaluate the impact on clinical management. Performances analysis, correlation among variables also considering semiquantitative parameters have been conducted. In the whole group of 80 patients at staging (N = 31) and restaging (N = 49), the detection rate of PSMA PET was 85% for all lesions. At staging, the performance analysis resulted in sensitivity 77.6%, specificity 89.5%, negative predictive value (NPV) 77.6%, positive predictive value (PPV) 89.5%, accuracy 85.7%, and area under curve (AUC) 0.87%. The performance of restaging PET in the group of patients with PSA values <1 ng/ml resulted in the following values: sensitivity 66.7%, specificity 92.9%, NPV 85.7%, PPV 81.3%, accuracy 82.6%, and AUC 0.79. Semiquantitative analysis revealed a mean value of SUVmax, metabolic tumor volume, and total lesion PSMA expression with differences in patients with high risk compared to low intermediate. At restaging PET, semiquantitative values of patients with total prostate specific antigen (tPSA) ≤ 1 ng/ml were significantly less than those of the tPSA > 1 ng/ml. A significant impact on clinical management was reported in 46/80 patients (57.5%) based on PSMA PET findings at staging and restaging. Although PSMA-PET provides optimal performances, its current role in redefining a better staging should be translated in the current clinical scenario about potential improvement in clinical/survival outcomes.

Twenty-year trends in prostate cancer stage and grade migration in a large contemporary german radical prostatectomy cohort.

A trend towards inverse stage migration in prostate cancer (PCa) was reported. However, previous analyses did not take into account potential differences in sampling strategies (number of biopsy cores), which might have confounded these reports. Within our single-institutional database we identified PCa patients treated with radical prostatectomy (RP) between 2000 and 2020 (n = 21,646). We calculated the estimated annual percentage change (EAPC) for D'Amico risk groups, biopsy Gleason Grade Group (GGG), PSA and cT stage as well as postoperative RP GGG and pT stage relying on log linear regression methodology. Subsequently, we repeated the analyses after adjustment for number of cores obtained at biopsy. Absolute rates of D'Amico low risk decreased (-30.1%), while intermediate and high risk increased (+21.2% and +9.0%, respectively). Rates of GGG I decreased (-50.0%), while GGG II-V increased, with the largest increase in GGG II (+22.5%). This trend, albeit less pronounced, was also recorded after adjusted EAPC analyses (p < .05). Specifically, EAPC values for D'Amico low vs intermediate vs high risk were -1.07%, +0.37%, +0.45%, respectively, and EAPC values for GGG ranged between -0.71% (GGG I) and +0.80% (GGG IV). Finally, an increase in ≥cT2 (EAPC: +3.16%) was displayed (all p < .001). These trends were confirmed in EAPC calculations in RP GGG and pT stages (p < .001). Our findings confirm the trend towards less frequent treatment of low risk PCa and more frequent treatment of high risk PCa, also after adjustment for number of biopsy cores.

Reply by Authors.

No AccessJournal of UrologyAdult Urology1 Jun 2021Reply by Authorsis a reply to letterEditorial Comment William C. Daly, Joshua A. Linscott, Paul K. J. Han, Matthew H. Hayn, Moritz H. Hansen, Stephen T. Ryan, Scot C. Remick, and Jesse D. Sammon William C. DalyWilliam C. Daly Maine Medical Center Research Institute, Portland, Maine Tufts University School of Medicine, Boston, Massachusetts Equal study contribution. More articles by this author , Joshua A. LinscottJoshua A. Linscott Maine Medical Center Research Institute, Portland, Maine Equal study contribution. More articles by this author , Paul K. J. HanPaul K. J. Han Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine More articles by this author , Matthew H. HaynMatthew H. Hayn Maine Medical Center Research Institute, Portland, Maine More articles by this author , Moritz H. HansenMoritz H. Hansen Maine Medical Center Research Institute, Portland, Maine More articles by this author , Stephen T. RyanStephen T. Ryan Maine Medical Center Research Institute, Portland, Maine More articles by this author , Scot C. RemickScot C. Remick Maine Medical Center Research Institute, Portland, Maine More articles by this author , and Jesse D. SammonJesse D. Sammon †Correspondence: Division of Urology & Center for Outcomes Research and Evaluation, Maine Medical Center, 509 Forest Ave., Suite 200, Portland, Maine 04101 telephone: 207-692-7167; E-mail Address: [email protected]; E-mail Address: [email protected] Maine Medical Center Research Institute, Portland, Maine Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001594.02AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Reply by Authors." The Journal of Urology, 205(6), pp. 1646–1647 Reference 1. : Implications of the United States Preventive Services Task Force recommendations on prostate cancer stage migration. Clin Genitourin Cancer 2021; 19: e12. Google Scholar © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of UrologyMar 18, 2021, 12:00:00 AMEditorial Comment Volume 205Issue 6June 2021Page: 1646-1647 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information William C. Daly Maine Medical Center Research Institute, Portland, Maine Tufts University School of Medicine, Boston, Massachusetts Equal study contribution. More articles by this author Joshua A. Linscott Maine Medical Center Research Institute, Portland, Maine Equal study contribution. More articles by this author Paul K. J. Han Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine More articles by this author Matthew H. Hayn Maine Medical Center Research Institute, Portland, Maine More articles by this author Moritz H. Hansen Maine Medical Center Research Institute, Portland, Maine More articles by this author Stephen T. Ryan Maine Medical Center Research Institute, Portland, Maine More articles by this author Scot C. Remick Maine Medical Center Research Institute, Portland, Maine More articles by this author Jesse D. Sammon Maine Medical Center Research Institute, Portland, Maine Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine †Correspondence: Division of Urology & Center for Outcomes Research and Evaluation, Maine Medical Center, 509 Forest Ave., Suite 200, Portland, Maine 04101 telephone: 207-692-7167; E-mail Address: [email protected]; E-mail Address: [email protected] More articles by this author Expand All Advertisement Loading ...

Implications of the United States Preventive Services Task Force Recommendations on Prostate Cancer Stage Migration.

Prostate-specific antigen screening is controversial. In 2008, the United States Preventive Services Task Force recommended against screening men aged≥ 75 years, and in 2012, expanded this to include all men. The impact of these changes continues to unfold. We hypothesized that these screening changes could delay the diagnosis of advanced prostate cancer. The Surveillance, Epidemiology, and End Results database was used to identify men (age, 55-69 years) diagnosed with prostate cancer in 2004 to 2008 (group 1), 2009 to 2012 (group 2), and 2013 to 2015 (group 3). Groups reflect United States Preventive Services Task Force guideline changes. Descriptive statistics were used to present baseline statistics and the number of patients diagnosed in aforementioned groups. Data was adjusted for population growth. A total of 328,586 men were identified (group 1, 135,625; group 2, 117,979; group 3, 74,982). The average number of men diagnosed annually with N1M0 (group 1, 381; group 2, 477; group 3, 660) and M1 (group 1, 523; group 2, 761; group 3, 1037) disease increased. With group 1 as control, there was a decrease in the incidence of localized disease (group 2, 9.2%; group 3, 33.2%). However, the incidence of N1M0 (group 2, 5.3%; group 3, 30.1%) and M1 disease (group 2, 22.6%; group 3, 49.2%) increased. Separate analyses of patients (age 50-75 years) and African Americans showed similar trends. With each recommendation, there was increased incidence of de novo metastatic prostate cancer. The sequelae of advanced disease include financial, emotional, and physical burden. Future studies are needed to identify screening strategies that reduce the risk of developing metastatic disease without over-diagnosing indolent cancers.

27-year patterns in high-risk prostate cancer treatment in a racially diverse, equal-access health care setting.

e16583 Background: Despite the significant stage migration of prostate cancer (CaP), a large proportion of patients harbor high-risk disease. Few CaP series provide long term outcomes with the ability to assess disparities in diverse populations. We examined 27-year outcomes among men treated for high risk CaP in a large, racially diverse, equal access system. Methods: A retrospective cohort study was conducted of patients enrolled into the Center for Prostate Disease Research (CPDR) Multi-Center National Database from 1990-2017. There were 2,241 CaP patients who were NCCN-defined high risk, had a self-reported race of Caucasian (CA) or African American (AA), and had a primary treatment of hormonal therapy (HT), radical prostatectomy (RP), radiation therapy (RT) or no treatment (NoTX). Demographic and clinico-pathological variables were evaluated and stratified by race and treatment. Primary study outcomes included temporal patterns in race-specific treatment intensity and type(s). Secondary outcomes included biochemical recurrence (BCR)-free survival (BRFS) and distant metastasis-free survival (DMFS). Unadjusted Kaplan-Meier estimation curves and multivariable Cox proportional hazards analysis were used. Results: Mean patient age at CaP diagnosis and follow-up time were 68.1 years and 7.8 years, respectively. AAs made up 26.9% of the study cohort. Median prostate specific antigen level was 20.9 ng/mL (IQR: 7.8 - 35.0). 52% of patients had a biopsy Gleason score of 8 or greater. 714 (31.9%) underwent RP, 966 (43.1%) underwent RT, 288 (12.9%) received primary HT, and 273 (12.2%) had NoTX. A decreasing trend of HT, with stable rates of RP and RT, was observed. Median time to BCR after RP and RT was 1.3 and 3.1 years, respectively. After RP and RT, 51.2% and 39.3% experienced BCR while 10.9% and 12.7% experienced distant metastasis, respectively. There were no significant racial differences in treatment intensity, treatment type, BRFS or DMFS. Conclusions: In this longitudinal series, there was racial comparability for all study outcomes. Moreover, in this high-risk patient series with long-term follow up (median = 6.9 years), nearly 50% did not experience BCR, and only 1 in 10 men developed metastasis.

Impact of the USPSTF recommendations on prostate cancer stage migration and de-novo metastatic prostate cancer.

166 Background: The US Preventive Services Task Force (USPSTF) recommended against prostate specific antigen (PSA) screening for men aged≥75 in 2008 and all men in 2012 in an effort to reduce overdiagnosis and overtreatment of men with prostate cancer (PCa). This recommendation may delay diagnosis of clinically significant PCa. Methods: The Surveillance, Epidemiology and End Results Program (SEER) was used to identify men diagnosed with PCa between 2004-2015. PCa stage was categorized as localized (N0M0), nodal (N1M0) and metastatic (NxM1). Trend analysis was stratified on age group (PSA screening eligible was defined as age 55-69 according to the 2018 updated USPSTF recommendation). Multivariable logistic regression was used to identify predictors for nodal and metastatic disease. Results: Between 2004-2015, there were 603,323 men with PCa identified. Metastatic disease accounted for 2.8% of PCa in 2004-2008, 3.7% in 2009-2012, and 6.1% in 2013-2015. In men eligible for PCa screening, metastatic disease increased from 1.9% in 2004-2008, to 2.6% in 2009-2012, to 4.2% in 2013-2015; nodal disease increased from 1.4% to 1.6% to 2.6%, respectively (both p-value for trend&lt; 0.0001). This stage migration was also observed in non-screening eligible groups (age &gt;70 and &lt;55). Compared with PCa diagnosed in 2009-2012, PCa diagnosed in 2013-2015 had higher odds of metastatic disease (AOR: 1.70, p-value&lt;0.0001) or nodal disease (AOR: 1.71, p-value&lt;0.0001). Conclusions: Men diagnosed with PCa in 2013-2015 were more likely to have metastatic or nodal disease, suggesting PCa stage migration since PSA screening was recommended to be discontinued in 2012. Although the impact of PSA screening on PCa mortality remains debatable, the reduced quality of life with advanced Pca should not be overlooked. Future population studies are warranted to investigate the influence of the updated 2018 USPSTF recommendation. [Table: see text]

Management of nonmetastatic castration-resistant prostate cancer.

The widespread use of prostate-specific antigen (PSA) resulted in stage migration of prostate cancer where androgen deprivation therapy (ADT) is administered for biochemical recurrence in patients following primary treatment. A proportion of these patients progress to a disease state termed nonmetastatic castration-resistant prostate cancer (nmCRPC), with a rising PSA despite ADT and without evidence of metastases on conventional imaging. We will review the treatment options in nmCRPC, especially in light of recent trials showing significant improvement in metastasis-free survival with newer agents. Historically, nmCRPC patients were followed-up if PSA doubling-time (PSADT) exceeded 10 months. Treatment options for patients with shorter PSADT included hormonal manipulations that often resulted in transient PSA decline. Denosumab was found to delay the onset of bone metastasis but did not impact survival. Recently, phase 3 trials showed that second-generation antiandrogens resulted in a significant delay in metastasis and a trend toward survival improvement in a select group of nmCRPC patients. The importance of reducing mortality and morbidity associated with metastasis has led to the acceptance of new primary endpoints in the design of trials for nmCRPC and might result in widespread approval of new agents for this disease state.

Inverse stage migration patterns in North American patients undergoing local prostate cancer treatment: a contemporary population-based update in light of the 2012 USPSTF recommendations.

Recent studies demonstrated ongoing inverse stage migration in prostate cancer (PCa) patients towards more advanced and unfavorable tumors. The USPSTF grade D recommendation may impact this trend in North American patients. We assessed contemporary stage migration and treatment trends in a large North American cohort diagnosed with PCa 2009-2014. Time-trend analyses were performed in patients within the Surveillance, Epidemiology, and End Results database, with complete data of clinical tumor stage, biopsy Gleason score, and validated PSA values, resulting in 211,645 assessable patients. Patients were stratified according to their different treatment methods [radical prostatectomy (RP), radiotherapy (RT), and no local treatment (NLT)] and according to clinical and pathological risk stratification (D'Amico and CAPRA-S score). Over time, proportions of D'Amico low-risk (LR) decreased, with an increase in intermediate-to-high-risk (IR/HR) patients. These trends were more distinct in men ≥ 70years. NLT proportions increased, most notably in D'Amico LR and/or older patients. Conversely, RP proportions remained stable in younger HR and increased in older HR patients. Similar patterns were demonstrated in the RP-treated subgroup: D'Amico HR, pT3, and/or lymph-node invasion or CAPRA-S HR proportions increased from 23.5 to 30.8, 24.3 to 32.9, and 10.7 to 16.3% (each p ≤ 0.015). Inverse stage migration with increase of unfavorable PCa continues in most contemporary North American patients. However, a paradigm shift to treat LR patients with less invasive methods (NLT) was demonstrated. Contrary, HR patients increasingly undergo LT. Future studies with long-term follow-up might answer if inverse stage migration vs. treatment trends translate into different PCa metastases/mortality rates vs. proposed NLT benefits, particularly related to USPSTF-recommended reduced PSA screening.

Is prostate cancer stage migration continuing for black men in the PSA era?

In the United States, disease-specific mortality from prostate cancer (PC) is highest among black men. While the introduction of widespread PSA testing has been associated with a downward stage migration, whether this trend continues in the late PSA era and for black men is unknown. The objective of our study was to evaluate current PC stage migration patterns in the United States by race. The Surveillance, Epidemiology and End Results (SEER) registry was queried to obtain all cases of PC reported between 2000 and 2013. Year of diagnosis was categorized into 2000-2003, 2004-2007, 2008-2010 and 2011-2013. Predictors of distant stage PC at diagnosis were determined using logistic regression adjusted for year of diagnosis, age at diagnosis, SEER region and race. A total of 791 184 PC cases were identified. The cohort comprised 78.9% (n=594 920) white and 14.1% (n=106 133) black men. The stage at diagnosis was 83.3% localized, 12.0% regional and 4.7% distant. Age-adjusted incidence demonstrated a steady decline for black men in all time groups while white men had a stable incidence of distant disease between 2000 and 2013. In univariate analysis, black men in the 2004-2007 (OR 0.86 (0.81-0.93)) and 2008-2010 cohorts (OR 0.85 (0.79-0.91)) were less likely to be diagnosed with metastatic PC as compared with the 2000-2003 baseline cohort. In multivariate analysis, the 2004-2007 black cohort was less likely to be diagnosed with distant PC (OR 0.90 (0.84-0.97)). This trend was not observed in white men who in multivariate analysis had an increased risk of distant PC in the 2004-2007 (OR 1.08 (1.04-1.11)), 2008-2010 (OR 1.22 (1.18-1.27)) and 2011-2013 (OR 1.65 (1.59-1.71)) groups. PC downward stage migration continues in black men but not in white men. Discontinuation of PSA-based screening for PC could disproportionately affect black men.

PD42-08 IS PROSTATE CANCER STAGE MIGRATION CONTINUING FOR BLACK MEN IN THE PSA ERA?

You have accessJournal of UrologyProstate Cancer: Staging I1 Apr 2016PD42-08 IS PROSTATE CANCER STAGE MIGRATION CONTINUING FOR BLACK MEN IN THE PSA ERA? Ryan Dobbs, David Greenwald, Harpreet Wadhwa, Vincent Freeman, and Michael Abern Ryan DobbsRyan Dobbs More articles by this author , David GreenwaldDavid Greenwald More articles by this author , Harpreet WadhwaHarpreet Wadhwa More articles by this author , Vincent FreemanVincent Freeman More articles by this author , and Michael AbernMichael Abern More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1760AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In the U.S., disease specific mortality from prostate cancer is highest among black men. The introduction of widespread prostate specific antigen (PSA) testing has been associated with a reduction in men presenting with metastatic disease and a significant shift towards a lower stage of disease on radical prostatectomy specimens. The objective of our study was to evaluate current prostate cancer stage migration patterns in the U.S. by race. METHODS The Surveillance, Epidemiology and End Results (SEER) registry was queried to obtain all cases of prostate cancer in adult males reported between 2000 and 2011. Stage at diagnosis and race were categorized using SEER definitions. For incidence trend analyses, data were reported as age-adjusted incidence per 100,000 U.S. population. Temporal trends in prostate cancer incidence rates by stage at diagnosis were performed using Poisson regression stratified by race. Predictors of distant stage prostate cancer at diagnosis were determined using logistic regression adjusted for year of diagnosis, age at diagnosis, SEER region, and race. RESULTS A total of 656,662 cases were identified. The median age was 67 years, and the race distribution was 79.1% white, 13.7% black, 4.6% other, and 2.5% unknown. The majority of the cases were diagnosed with localized prostate cancer (83.7%), however 11.9% were diagnosed with regional disease and 4.4% with distant disease. Black race (OR 1.95 [1.89-2.02], p<0.01), and older age (OR 1.07/year [1.06-1.07], p<0.01) were associated with distant prostate cancer at diagnosis. Age at diagnosis <55 years was associated with a reduced likelihood of distant stage at diagnosis (OR 0.63 [0.60-0.66], p<0.01). The incidence rate of distant prostate cancer tended to decline over the study period for black men (OR 0.97/year [0.93-1.00], p=0.05), but not for white men (OR 0.99/year [0.95-1.03], p=0.56). CONCLUSIONS In the contemporary PSA era prostate cancer stage migration towards a lower stage of disease is still occurring among black men but appears to have stabilized among white men. Discontinuation of PSA-based screening for prostate cancer could disproportionately affect black men, whom, as a group, remain most likely to be diagnosed with metastatic and potentially fatal disease. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e990 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Ryan Dobbs More articles by this author David Greenwald More articles by this author Harpreet Wadhwa More articles by this author Vincent Freeman More articles by this author Michael Abern More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Transrektalna ultrazvočna preiskava in igelna biopisja prostate

In the last 25 years widespread use of prostatic specific antigen caused a stage migration of prostate cancer towards localized disease at diagnosis, which resulted in transrectal ultrasound biopsy to become standard in clinical practice. Transrectal ultrasound examination of the prostate is used to diagnose benign prostatic diseases, e.g. benign prostatic enlargement, prostatitis, prostatic and seminal vesicle cysts. It is also important in detection of obstructive causes of male infertility. Transrectal ultrasound examination is performed most often in needle biopsy for prostate cancer diagnosis. Besides guiding systematic tissue core biopsy, characteristic ultrasound changes enables target biopsies of suspect areas. The article describes indications, contraindications, antibiotic prophylaxis, various biopsy templates and complications of the needle biopsy. Experience with transrectal ultrasound guided biopsy at Department of urology at University medical center in Ljubljana is presented.

MP24-07 TIME TRENDS IN THE USE OF SECONDARY TREATMENTS FOR BIOCHEMICAL RECURRENCE AFTER RADICAL PROSTATECTOMY

INTRODUCTION AND OBJECTIVES: Despite a downward stage migration in prostate cancer (PCa) over the last decades, there has been an increase in the use of radiotherapy and radical prostatectomy (RP) as primary treatments. However, it is unknown whether a shift toward more aggressive approaches also occurred in the treatment of biochemical recurrence (BCR) following RP. In addition, it is unclear whether the time trends in the use of treatments for BCR correlate with changes in the severity of BCR over time. Herein, we analyzed the time trends of BCR severity and the use of secondary treatments for BCR after RP. METHODS: We analyzed data from 3434 men with BCR after RP for PCa at Mayo Clinic from 1987 to 2012. Cumulative incidence (CI) of secondary treatments (overall, radiotherapy [RT], and androgen deprivation therapy [ADT]) were estimated using life-table methods adjusting for competing risk of systemic progression and death. The effect of BCR year was estimated using Cox proportional hazard models unadjusted and adjusted for clinicopathologic features. Chisquared test was used to analyze BCR severity (PSA levels and PSADT in groups) by BCR year. RESULTS: Overall, 1891 (55%) patients received any form of treatment for BCR, 1224 (36%) received RT, and 1296 (38%) ADT over a median follow-up time of 8.0 years after BCR (interquartile range 1⁄4 3.9-12.6). On univariable analysis, more recent BCR year was associated with a higher CI of RT (HR1⁄41.02, P<0.001), lower CI of ADT (HR1⁄40.98, P<0.001), and slightly lower CI of any secondary treatments (HR1⁄40.99, P1⁄40.023). On multivariable analysis, more recent BCR year was associated with higher CI of overall secondary treatments (HR1⁄41.02, P<0.001), RT (HR1⁄41.04, P<0.001), and similar ADT (HR1⁄41.00, P1⁄40.85). Conversely, the severity of BCR as measured by PSA and PSADT at BCR decreased in more recent years (P < 0.001). CONCLUSIONS: Despite less aggressive BCR in more recent years, patients were more frequently treated with RT over time. These results suggest a shift toward more aggressive approaches for BCR after RP in more recent years.

MP42-19 TIME TRENDS IN CLINICOPATHOLOGIC DEMOGRAPHICS OF MEN WITH HIGH-RISK PROSTATE CANCER UNDERGOING RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Staging II1 Apr 2014MP42-19 TIME TRENDS IN CLINICOPATHOLOGIC DEMOGRAPHICS OF MEN WITH HIGH-RISK PROSTATE CANCER UNDERGOING RADICAL PROSTATECTOMY Sarah Psutka, R. Jeffrey Karnes, Suzanne Stewart, R. Houston Thompson, Matthew Tollefson, Carlson Rachel, Laureano Rangel, Eric Bergstralh, and Stephen Boorjian Sarah PsutkaSarah Psutka More articles by this author , R. Jeffrey KarnesR. Jeffrey Karnes More articles by this author , Suzanne StewartSuzanne Stewart More articles by this author , R. Houston ThompsonR. Houston Thompson More articles by this author , Matthew TollefsonMatthew Tollefson More articles by this author , Carlson RachelCarlson Rachel More articles by this author , Laureano RangelLaureano Rangel More articles by this author , Eric BergstralhEric Bergstralh More articles by this author , and Stephen BoorjianStephen Boorjian More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1196AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives While a stage migration in prostate cancer has been well-recognized over the PSA era, temporal changes in the demographics of patients with high-risk disease (HrPC) continue to be defined. Herein, we report time trends in clinicopathologic features of men undergoing radical prostatectomy (RP) for HrPC. Methods We reviewed 18,299 patients treated with RP at Mayo Clinic between 1990-2011 to identify 2083 men with HrPC. HrPC was defined by NCCN criteria: biopsy Gleason score 8-10 and/or PSA > 20ng/mL and/or clinical stage ≥ T3. Patients were classified as early PSA era (1990-1997), mid PSA era (1998-2004), and late PSA era (2005-2011). Clinicopathologic demographics were compared using the Kruskal-Wallis and Pearson’s/Mantel-Haenszel Chi-square tests. Results The percentage of all patients undergoing RP in each era who were classified as high-risk decreased significantly over time, from 23.5% of RPs in the early PSA era to 10.5% in the mid PSA era to 9.5% the late PSA era (p<0.0001). Temporal trends in clinicopathologic features are depicted in the Table. More recent patients were significantly younger, with a lower PSA and lower clinical stage but with a higher biopsy Gleason score (all p<0.0001). The prevalence of patients with HrPC according to a single criteria significantly increased over time, from 78.6% to 83.2% to 87% (p=0.0001), while the prevalence of patients with two high-risk criteria decreased (19.3% vs 15.9% vs 11.9%; p=0.0007). Moreover, the rate of seminal vesicle invasion, positive surgical margins, and tumor volume significantly decreased, although the rate of Gleason 8-10 disease increased during the study period (all p<0.0001). Meanwhile, the rate of lymph node involvement was relatively stable from early (18.4%) to late PSA era (17.9%), as were the median number of lymph nodes removed (10 and 11, respectively, from early and late PSA eras). Conclusions HrPC represented a decreasing proportion of surgical cases over the course of the PSA era. Overall pathologic features have become more favorable in these men. Notably, an increasing percentage of patients are characterized as high-risk based on Gleason score, which may reflect prostate cancer stage migration and/or changes in Gleason grade assignment. Clinicopathologic characteristics of HrPC patients over time Variable Early PSA (n = 1066) Mid PSA (n = 471) Late PSA (n = 546) p-value Median age at RP (IQR) 66 (62, 70) 65 (58, 69) 64 (58, 69) < 0.0001 Median (IQR) preoperative PSA (ng/ml) 23.1 (10.3, 36) 13.4 (6.2, 25) 8.5 (5.3, 21.5) < 0.0001 Clinical tumor stage (%) (n=2056) cT1 158 (14.9) 159 (34.3 204 (38.5) < 0.0001 cT2 468 (44) 202 (43.5) 252 (47.5) cT3/4 436 (41.1) 103 (22.2) 74 (14) Biopsy Gleason score (%) (n=1751) bGS < = 6 328 (44.3) 117 (25.1) 39 (7.2) < 0.0001 bGS 7 196 (26.5) 99 (21.2) 115 (21.2) bGS 8 217 (29.3) 251 (53.7) 389 (71.6) Pathologic tumor stage pT2 374 (43) 237 (55.8) 262 (58.5) < 0.0001 pT3a 238 (27.4) 91 (21.4) 116 (25.9) pT3b 250 (28.7) 94 (22.1) 66 (14.7) pT4 8 (0.9) 3 (0.7) 4 (0.9) Pathologic Gleason score < = 6 427 (40.2) 89 (18.9) 29 (5.3) < 0.0001 7 465 (43.7) 180 (38.2) 243 (44.6) 8 - 10 171 (16.1) 202 (42.9) 273 (50.1) Positive Surgical Margins (%) 662 (62.1) 214 (45.4) 182 (33.3) < 0.0001 © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e475-e476 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Sarah Psutka More articles by this author R. Jeffrey Karnes More articles by this author Suzanne Stewart More articles by this author R. Houston Thompson More articles by this author Matthew Tollefson More articles by this author Carlson Rachel More articles by this author Laureano Rangel More articles by this author Eric Bergstralh More articles by this author Stephen Boorjian More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Nationwide, population-based study of prostate cancer stage migration between and within clinical risk categories

Objective. In countries with widespread prostate cancer screening there has been strong stage migration, but little is known about changes within clinical risk categories. Such data are important for the proper interpretation of studies that recruited cases in an earlier era. The purpose of this study was to examine stage migration between and within clinical risk categories. Material and methods. Using the population-based National Prostate Cancer Register (NPCR) of Sweden, changes in the distribution of prostate-specific antigen (PSA), Gleason score, tumor stage and volume overall between and within clinical risk categories were examined in 120 228 prostate cancer cases diagnosed from 1998 to 2011. Results. Between 1998 and 2011, there was a two-fold increase in the proportion of low-risk prostate cancer (stage T1/T2, Gleason score 2–6 and PSA <10 ng/ml), from 14% to 28%, and more than a two-fold decrease in the proportion of metastatic disease, from 25% to 11%. The proportion of men in the low-risk category with T1c tumors increased two-fold, from 36% to 71%, and PSA levels between 4 and 6 ng/ml increased from 24% to 38%; T2 tumors decreased from 39% to 20% and PSA between 8 and 10 ng/ml decreased from 24% to 15%. The proportion of men with less than 25% of cores involved with cancer increased from 41% to 52% between 2003–2006 and 2007–2011. Conclusions. Low-risk cases today have substantially lower tumor volume and PSA levels than low-risk cases diagnosed in 1998, indicating that outcomes in studies that recruited cases in previous decades represent worst case scenarios.

Current status of radical prostatectomy for high-risk prostate cancer.

Despite the wide application of prostate-specific antigen-based screening leading to a profound stage migration in prostate cancer (PC), a significant percentage of men are still being diagnosed with clinically high-risk disease that requires aggressive treatment. Optimal management in these patients remains challenging, and strong advocates for radical prostatectomy (RP), radiotherapy, androgen deprivation therapy, and, increasingly, a multimodal approach abound. Currently, surgery for high-risk PC is frequently applied. RP offers an attractive opportunity for tumor excision either as a definitive management or as a first step in multimodal therapy. Nevertheless, this approach is still controversial. In this review, we discuss the current evidence for the role of RP in this clinical setting, including surgical considerations and outcomes. The role of robot-assisted RP, which is increasingly utilized in Korea in this clinical scenario, is discussed.

Extended pelvic lymph node dissection in prostate cancer: a 20-year audit in a single center

BackgroundWe set to assess the impact of stage migration in prostate cancer (PCa) on the evolution of the pN1 rate and tumor characteristics in pN1 patients over the last two decades. Patients and methodsWe evaluated 5274 PCa patients treated with radical prostatectomy and anatomically extended pelvic lymph node dissection (ePLND) between 1990 and 2010. Year-per-year trends of clinical and pathological characteristics were examined. Logistic regression analyses addressed predictors of pN1. ResultsThe median number of lymph nodes (LNs) removed was 16.0. Overall, the pN1 rate was 13.8% and it decreased from 26.1% to 15.6% between 1990 and 2010 (P < 0.001). For the same period, the pN1 rate changed from 0% to 3% in the low-risk PCa, from 20% to 7% in the intermediate-risk PCa, and from 33% to 44% in the high-risk PCa (P ≤ 0.01). In pN1 patients, pre-operative cancer characteristics and the median number of positive LNs (three in 1990 versus two in 2010) did not significantly change overtime (all P ≥ 0.1). Year of surgery was not an independent predictor of pN1 (all P ≥ 0.06). ConclusionBased on ePLND outcomes, contemporary patients with intermediate- and high-risk PCa's still harbor a significant LNI risk. In consequence, stage migration does not justify omitting or limiting the extent of PLND in these individuals.

Ensuring quality for radical prostatectomies in Canada

The number of radical prostatectomies (RP) performed across Canada has increased from 3 per 100 000 in 1980/81, to 71 per 100 000 in 1998/99.1 About 130 000 patients are living with or surviving prostate cancer. The number of new cases of prostate cancer across Canada in 2006 was 22 480,2 and the incidence across the provinces is fairly similar.1 The current guidelines, although arising from Ontario, have important implications to urological practice nationally. This guideline makes recommendations on the surgical and pathological aspects of the management of prostate cancer, and supports the multidisciplinary management of prostate cancer.3 This approach is not without its critics.4 It has been, however, recently shown that over a third of patients undergo a change in treatment or diagnosis with this approach.5 It is certainly helpful for more complex cases; dedicated uro-pathological input is invaluable. There are several surgical aspects covered in these guidelines. The careful consideration suggested for high-risk patients applies equally to low-risk patients, in whom active surveillance should be prioritized. Furthermore, a multimodality approach with primary RP and adjuvant or salvage radio-therapy where appropriate, should be considered for high-risk patients. Recent data6 (including our own unpublished data) suggest equivalent or better biochemical progression-free and cancer-specific survival rates compared to the traditional approach of radiotherapy and androgen deprivation therapy in these patients. High-risk patients undergoing RP also experience comparable morbidity to RP for lower risk disease, in addition to several other benefits.7 With regard to pelvic lymph node dissection (PLND), risk-stratification will spare low-risk patients the potential morbidity of PLND. Controversy surrounds the extent of PLND in high-risk patients. The European Association of Urology recommends that all high-risk patients should undergo an extended PLND due to the fact that 15% to 40% of patients have positive lymph nodes. However, there is an absence of modern data demonstrating a survival benefit with this approach, therefore standard PLND is adequate in these patients. In recent years there has been debate on the importance of positive surgical margins (PSM). With the advent of prostate-specific antigen testing and subsequent stage migration of prostate cancer, PSM-rates have fallen. Furthermore, most patients with a PSM do not recur. As a result there is some suggestion that the predictive value of a PSM has decreased.8 A PSM is an important surgical outcome which, on univariate and multivariate analysis, is an independent risk factor for biochemical recurrence9 and as such should be kept as low as possible. This underlines the importance of detailed uro-pathological assessment of PSMs in terms of location and size, information which is required if subsequent decisions regarding adjuvant or salvage treatments are to be made. Improvements in surgical technique have meant that the incidence of rectal injury and the need for blood transfusion have fallen over the years. Furthermore a better understanding of the relevant anatomy means that nerve-sparing techniques can and should be offered in appropriate patients. However, constructing guidelines regarding functional outcomes, such as incontinence and erectile dysfunction following RP, is more difficult. Published series vary widely in their rates and have been criticized for not using validated assessment tools pre- and postoperatively.10 What is important is the ability to counsel patients regarding their likely functional outcome according to local data. These are the first published guidelines regarding the surgical and pathological outcomes following RP in Canada, and reinforce what many in the field would consider current best practice. If these guidelines are to ensure quality in the provision of surgery for patients with prostate cancer, the prospective and accurate collection of local departmental outcome data is essential. Many health-care systems have centralized cancer services according an arbitrary minimum volume of patients required to achieve continued competency. Publishing minimum standards for outcome as achieved in the present paper maybe a better method to ensure competency. A difficult issue will be with a centre not achieving the set standards.

Focal cryosurgical ablation of the prostate: a single institute’s perspective

BackgroundWith the stage migration of prostate cancer witnessed in the late 1990’s and early 2000’s along with the persistent morbidities associated with prostatectomy and radiation therapy, the concept of focal prostate cancer treatment remains quite attractive. Herein we evaluate the tolerability and non-oncologic outcomes of a highly select cohort of men that underwent focal cryoablation of the prostate for the treatment of localized prostate cancer.MethodsPre-operatively, erectile function was assessed by SHIM questionnaire while voiding symptoms were assessed by AUA symptom score. Twenty-six highly select patients (23 low-risk prostate cancer and 3 intermediate-risk prostate cancer) with documented minimal disease on saturation prostate biopsy underwent focal cryoablation of the prostate (24 hemi-ablation and 2 subtotal ablation). Subsequently, serum PSAs were obtained every 3 months for 2 years and then every 6 months thereafter. PSA failure was defined as an increase of 0.50 ng/ml over nadir. Mean follow-up was 19.1 months. Subjective assessment of erectile function and voiding was assessed post-operatively at each visit.ResultsBased on our PSA failure definition, 11.5% (3 patients) of the cohort experienced biochemical failure. In two of the three patients, localized disease was detected on subsequent transrectal ultrasound guided biopsy. These two patients went on to have favorable PSA nadirs after undergoing conventional definitive therapy (one patient had external beam radiation and one patient had whole gland cryoablation). Within the study cohort, 27% (7 patients) reported new post-operative erectile dysfunction requiring therapy while no patients reported new post-operative urinary incontinence or worsening of voiding symptoms.ConclusionThese preliminary results add to the expanding body of literature that the minimally invasive focal cryosurgical ablation of the prostate is a safe procedure with few side effects. The true extent of cancer control remains in question, but in highly select patients, favorable PSA kinetics have been demonstrated. If confirmed by further studies with long-term follow-up, this treatment approach could have a profound effect on prostate cancer management.

Diagnostic dilemma in histopathology report following robot assisted laparoscopic prostatectomy: Tumour ′hide and seek′

Widespread PSA (prostate specific antigen) screening has resulted in stage migration of prostate cancer. Smaller tumor volumes are being detected in radical prostatectomy specimens. This has coincided with increasing reports about the 'vanishing cancer phenomenon.' To analyse the cases of robot assisted laparoscopic prostatectomy (RALP) at our institute in which the pre operative prostate biopsy was positive for adenocarcinoma but no tumor could be identified in the final histopathology, and to review the literature for possible reasons for such a phenomenon. Nine patients were identified out of a total of 184 cases of RALP in which the final histopathology did not correlate with the initial biopsy report. The initial biopsy slides as well as the final histopathology slides were reviewed by a second pathologist. The specimens were processed in entirety and additional sections were taken until no tissue was left. Two patients had cancer diagnosed on TURP (transurethral resection of prostate) chips, while the remaining patients had undergone TRUS biopsy for elevated PSA. The final histopathological diagnosis was benign prostatic hyperplasia in two patients, chronic prostatitis in four patients, and acute florid prostatitis in one patient, granulomatous prostatitis with glandulostromal hyperplasia in one patient and TCC (transitional cell carcinoma) of prostate in one patient. Most cases of pT0 are due to inability of routine histopathological analysis to identify minute tumor focus. Urologists need to be aware of this in view of the potential medico legal implications.

Impact of the introduction of a robotic training programme on prostate cancer stage migration at a single tertiary referral centre

To evaluate the trend in robot-assisted radical prostatectomy (RARP) and open retropubic radical prostatectomy (RRP) use over time and to compare preoperative and pathological characteristics of patients treated with RARP or RRP at a single centre. Between 2006 and 2010, 2511 consecutive patients treated with RP, with or without pelvic lymph node dissection (PLND), for prostate cancer (PCa) at a single tertiary care centre were analysed. Baseline patient characteristics and PCa risk distribution were compared according to treatment type (RRP vs RARP) in the overall population, as well as in three surgeons' initial 50 RARP and three surgeons' initial 50 RRP cases (n = 300). We used a chi-squared trend test to evaluate the differences in treatment type administration over time according to PCa characteristics. Logistic regression analyses focused on the prediction of PLND and adjuvant radiotherapy (RT) use. Overall, 1873 (74.6%) and 638 (25.4%) patients underwent RRP and RARP, respectively. Men treated with RARP were younger (mean age: 62 vs 65 years), less obese (mean BMI: 24.8 vs 26.4 kg/m(2) ), healthier (Charlson comorbidity index = 0: 68.7 vs 53.3%) and more likely to harbour clinical low-risk PCa (51 vs 30%) than their RRP counterparts (all P < 0.001). Similar findings were observed in sub-analyses focusing on six surgeons' 50 initial patients (all P ≤ 0.02). A significant increase in the rate of patients with low-risk PCa treated with RARP vs RRP was reported over time (5 vs 95% and 66 vs 34% in 2006 and 2010, respectively). Conversely, 76% of patients with high risk PCa were still treated with RRP in 2010. Patients treated with RARP were less likely to receive PLND at RP and adjuvant RT (all P ≤ 0.01), even after adjusting for clinical and PCa characteristics. The introduction of a robotic training programme at a high volume centre led to significant patient selection in terms of clinical and PCa characteristics. When both RRP and RARP facilities are available within the same centre, patients with the most favourable clinical and cancer profile are selected to undergo RARP. Use of RARP negatively influenced the rates and the extent of PLND as well as the use of adjuvant RT after surgery. Thus, baseline patient selection, surgical and treatment biases make any comparisons of RARP with RRP problematic.