Prostate-specific Antigen Surveillance Research Articles

Posttreatment surveillance intensity and overall survival in prostate cancer survivors (AFT-30).

Posttreatment surveillance affects millions of cancer survivors, but empiric data to guide clinical practice are lacking. This study assessed whether the intensity of surveillance testing after radical prostatectomy or radiation therapy for localized prostate cancer is associated with overall survival. Men diagnosed with localized prostate cancer between 2005 and 2010 who underwent radical prostatectomy or radiation therapy at a Commission on Cancer-accredited facility were randomly sampled. Primary data collected from 10147 patients sampled across 1007 facilities were linked with existing data from the National Cancer Database. Analysis examined whether intensity of surveillance measured as the number of prostate-specific antigen (PSA) tests in the first year after primary treatment (categorized as 0-1 [low intensity], 2 [medium], or ≥3 [high intensity] PSA tests) was associated with overall survival. Secondary outcomes included recurrence-free survival (RFS) and subsequent use of imaging tests, biopsy procedures, and salvage treatment. Median follow-up exceeded 8 years from prostate cancer diagnosis. Overall survival was not statistically significantly different across surveillance intensity groups among radiation therapy (P = .59) or radical prostatectomy (P = .29) patients. RFS was not statistically significantly different across surveillance intensity groups for radiation therapy (P = .13) patients but was for radical prostatectomy (P = .01) patients with high intensity associated with the worst RFS. In both treatments, higher surveillance intensity was associated with more procedures and salvage treatments. In patients with localized prostate cancer, more frequent PSA surveillance testing after radical prostatectomy or radiation therapy was associated with increased procedures and salvage treatments but not overall survival.

Socioeconomic Barriers to Receiving Early Salvage Radiotherapy for Locally Advanced Prostate Adenocarcinoma: A Retrospective Single-Center Study.

Purpose This study aimed to identify factors associated with delays in initiating early salvage radiation therapy in prostate cancer patients with prostate-specific antigen (PSA) failure after prostatectomy. Methods We conducted a single-institution, retrospective study of patients receiving salvage radiation therapy after radical prostatectomy from 2011 to 2022. Patient demographics and clinical data were examined to identify factors that may have influenced the time to start of radiation therapy after surgery. Utilizing a PSA cut off of 0.25 ng/ml or less, we classified patients as receiving either early "PSA low" or late "PSA high" salvage therapy depending on their PSA at the time of initiating treatment. Results Of the 81 patients evaluated, the median age was 61.9 years (IQR 57.9 - 66.5), with most presenting with pT3 (65.4%), Grade Group 2 disease (35.8%), and positive margins 55%). Median PSA at salvage radiation therapy commencement was 0.30 ng/mL (0.18 - 0.48). 40 patients completed early salvage and 41 patients completed late salvage in the overall cohort. A significant association was found between patient insurance carrier and pre-radiation PSA levels. Patients with HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization) insurance were more likely to complete late salvage radiation compared to non-managed Medicare patients (HMO OR 4.0, p <0.05 & PPO OR 3.3 p <0.05 vs non-managed Medicare). All uninsured patients in the cohort received late salvage radiation. Conclusions Insurance type was significantly associated with the timing of salvage radiation therapy post-prostatectomy, suggesting a relationship with providers requiring prior authorization (HMO and PPO coverage). This study supports proper PSA surveillance, in particular for those with HMO or PPO coverage.

Conditional Survival Probabilities in Recurrent Prostate Cancer (PCa) Patients Receiving Radiation ± Antiandrogen Therapy: Secondary Analysis of a Randomized Clinical Trial

<h3>Purpose/Objective(s)</h3> Salvage radiation therapy (SRT) and androgen-deprivation therapy (ADT) are routinely used in patients with elevated prostate-specific antigen (PSA) levels after radical prostatectomy (RP). Although overall survival (OS) and biochemical-failure (BF) following SRT are useful when counseling patients at the time of treatment, the utility of survival data from time of diagnosis diminishes over time. Conditional survival (CS) can provide more relevant estimates, especially given long-term PCa survivorship. The primary aim of this study was to analyze CS estimates for recurrent PCa patients undergoing SRT ± ADT. The secondary objective was to determine if factors prognostic of OS and BF at diagnosis remain relevant in survivorship. <h3>Materials/Methods</h3> We analyzed data from 760 post-RP patients enrolled in NRG/RTOG 9601 (1998–2003). Eligible patients included men who had undergone prior RP and had pT2/T3 disease without nodal involvement and detectable PSA levels of 0.2–4.0 ng/mL. Patients were randomly assigned to undergo SRT and receive either 24 mo of ADT or placebo. OS was calculated (Kaplan–Meier), cumulative incidence was used to estimate BF rates, and prognostic factors associated with OS and BF were analyzed by multivariable Cox proportional hazards modeling (MVA). <h3>Results</h3> Patients were followed for a median of 13 y. The 5- and 10-y OS estimates from diagnosis were 93% and 80%, respectively. At 1- (<i>n</i> = 755), 3- (<i>n</i> = 727), 5- (<i>n</i> = 680), 8- (<i>n</i> = 602), and 10-y (<i>n</i> = 543) survivorship, chances of surviving an additional 5 y were 92%, 89%, 86%, 80%, and 72%, respectively. On MVA at diagnosis, omission of ADT (HR 1.308, <i>P</i> = 0.0403), increasing age (HR 2.761, <i>P</i> < 0.0001), and Gleason score (GS) 8−10 (HR 1.054, <i>P</i> =0.01), were associated with all-cause mortality. For those who achieved survivorship at 5 y, only age (HR 2.973, <i>P</i> < 0.0001) and GS 8–10 (HR 1.801, <i>P</i> = 0.0063) were prognostic of mortality on MVA. The 5- and 10-y rates of BF from diagnosis were 36% and 52%, respectively. For patients who survived 1 (<i>n</i> = 725), 3 (<i>n</i> = 560), 5 (<i>n</i> = 435), 8 (<i>n</i> = 320), and 10 (<i>n</i> = 268) y without BF, chances of BF at an additional 5 y were 39%, 33%, 26%, 20%, and 20%, respectively. On MVA at time of SRT, omission of ADT (HR 2.139, <i>P</i> < 0.0001), GS 7 (HR 1.376, <i>P</i> = 0.0062), GS 8–10 (HR 1.717, <i>P</i> = 0.0005), and higher pretreatment PSA (HR 1.442, <i>P</i> = 0.0215), were associated with BF. For those who survived 5 y after treatment without failure, only omission of ADT (HR 1.407, <i>P</i> < 0.0384) was prognostic of BF. <h3>Conclusion</h3> Conditional risk of BF for patients treated with SRT remains elevated at levels similar to those at initial treatment for up to 3 y after SRT, after which BF rates decrease. ADT continues to confer a reduced risk for BF for long-term survivors. This data can be used to inform survivorship care planning and highlights the need for continued PSA surveillance after completion of treatment.

Intensity of observation with active surveillance or watchful waiting in men with prostate cancer in the United States.

Population-based studies assessing various active surveillance (AS) protocols for prostate cancer, to date, have inferred AS participation by the lack of definitive treatment and use of post-diagnostic testing. This is problematic as evidence suggests that most men do not adhere to AS protocols. We sought to develop a novel method of identifying men on AS or watchful waiting (WW) independent of post-diagnostic testing and aimed to identify possible predictors of follow-up intensity in men on AS/WW. A predictive model was developed using SEER watchful waiting data to identify men ≥66 years on AS between 2010-2015, irrespective of post-diagnostic testing, and applied to SEER-Medicare database. AS intensity among different variables including age, prostate-specific antigen (PSA) level, number of total and positive biopsy cores, Charlson comorbidity index, race (Black vs. non-Black), US census region, and county poverty, income, and education levels were compared using multivariable regression analyses for PSA testing, surveillance biopsy, and magnetic resonance imaging (MRI). A total of 2238 men were identified as being on AS. Of which, 81%, 33%, and 10% had a PSA test, surveillance biopsy, and MRI scan within 1-2 years, respectively. On multivariable analyses, Black men were less likely to have a PSA test (adjusted rate ratio [ARR] 0.60, 95% CI: 0.53-0.69), MRI scan (ARR 0.40, 95% CI: 0.24-0.68), and surveillance biopsy (ARR 0.71, 95% CI: 0.55-0.92) than non-Black men. Men within the highest income quintile were more likely to undergo PSA test (ARR 1.16, 95% CI: 1.05-1.27) and MRI scan (ARR 1.60, 95% CI 1.15-2.27) compared to men with the lowest income. Black men and men with lower incomes on AS underwent less rigorous monitoring. Further study is needed to understand and ameliorate differences in AS rigor stemming from sociodemographic differences.

PD03-03 REAL-WORLD ACTIVE SURVEILLANCE IMPLEMENTATION IN BLACK MEN WITH PROSTATE CANCER IN THE US

You have accessJournal of UrologyHealth Services Research: Practice Patterns, Quality of Life and Shared Decision Making I (PD03)1 Sep 2021PD03-03 REAL-WORLD ACTIVE SURVEILLANCE IMPLEMENTATION IN BLACK MEN WITH PROSTATE CANCER IN THE US Bashir Al Hussein Al Awamlh, Patrick Lewicki, Spyridon Basourakos, Xian Wu, Jim Hu, and Jonathan Shoag Bashir Al Hussein Al AwamlhBashir Al Hussein Al Awamlh More articles by this author , Patrick LewickiPatrick Lewicki More articles by this author , Spyridon BasourakosSpyridon Basourakos More articles by this author , Xian WuXian Wu More articles by this author , Jim HuJim Hu More articles by this author , and Jonathan ShoagJonathan Shoag More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001967.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is a growing body of evidence suggesting that Black men on active surveillance (AS) should be followed more carefully than non-Black men because they harbor more aggressive disease and experience higher rates of progression. However, it is unclear if the intensity of AS monitoring in Black men is similar to non-Black men in a population-based setting. We aimed to develop a novel method to identify men on AS and compare the intensity of AS in Black men with indolent prostate cancer to non-Black in the US. METHODS: Retrospective cohort study of men aged ≥66 years with indolent prostate cancer managed with AS in the US between 2010-2015. A predictive model was developed using SEER watchful waiting data to identify men that were managed with AS in the SEER-Medicare claims database. AS intensity in Black men compared to non-Black men was determined using multivariable Poisson regression analyses for prostate-specific antigen (PSA) testing, surveillance biopsy and magnetic resonance imaging (MRI) scans. RESULTS: A total of 2,123 (94.9%) non-Black and 115 (5.1%) Black men that underwent AS were included. The median follow-up time was 1.73 years (interquartile range 0.93-2.92 years). Among all men enrolled in AS, 81% had a PSA test, 33% had a surveillance biopsy and 10% had an MRI scan within 1-2 years, respectively. In multivariable analyses, Black men were less likely to have a PSA test (adjusted rate ratio [ARR] 0.60, 95% confidence interval [CI] 0.53-0.69), MRI scan (ARR 0.40, 95% CI 0.24-0.68) and surveillance biopsy (ARR 0.71, 95% CI 0.55-0.92) than non-Black men (Figure). CONCLUSIONS: Black men with prostate cancer on AS undergo less rigorous monitoring than non-Black men in the US in a population-based setting. These data are concerning given the higher susceptibility of Black men for disease progression. Efforts to improve AS rigor in Black men should be a priority for policymakers. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e43-e44 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bashir Al Hussein Al Awamlh More articles by this author Patrick Lewicki More articles by this author Spyridon Basourakos More articles by this author Xian Wu More articles by this author Jim Hu More articles by this author Jonathan Shoag More articles by this author Expand All Advertisement Loading ...

Race and prostate specific antigen surveillance testing and monitoring 5-years after definitive therapy for localized prostate cancer.

Prostate-specific antigen (PSA) surveillance testing is a cornerstone of prostate cancer survivorship because patients with biochemical recurrence often have no symptoms. However, the investigation of guideline-concordant PSA surveillance across racial groups is limited. We examined racial differences in PSA surveillance testing 5-years post-definitive treatment for localized prostate cancer. We created a population-based retrospective cohort from the Surveillance, Epidemiology, and End Results-Medicare linked database for men diagnosed with prostate cancer between the years 2007 to 2011 with Medicare claims through 2016 (N = 21,372). Multivariable log-binomial regression models were used to examine the effect of race on the likelihood of not receiving at least one PSA surveillance test annually 5-years post-definitive treatment. Black men had 90%, 71%, 44%, 34%, and 23% increased risk of not receiving at least one PSA surveillance test annually in the first, second, third, fourth, and fifth years of post-definitive treatment follow-up, respectively. The adjusted relative risk [ARR] for Black men compared to White men were 1.68 (95% Confidence Interval [CI], 1.37-2.07), 1.52 (95% CI, 1.32-1.75), 1.32 (95% CI, 1.17-1.48), and 1.16 (95% CI, 1.05-1.29) in the first, second, third, and fourth year of post-definitive treatment, respectively. Black men were more likely not to receive guideline-concordant PSA surveillance testing following definitive treatment for localized prostate cancer during the first 4 years post-treatment. This study suggest room for improvement in defining survivorship care plans for Black men to increase use of PSA surveillance testing.

Reverse intermittent androgen deprivation therapy: Prostate cancer and hypopituitarism

Testosterone replacement in the context of untreated prostate cancer is a controversial topic, where the symptomatic benefits of testosterone therapy contrast with the risk of disease progression. We report the case of a 76-year-old gentleman, under watchful waiting for known prostate cancer, who underwent a transsphenoidal resection of a pituitary macroadenoma. The adenoma and subsequent surgical treatment resulted in secondary testosterone deficiency, effectively ‘self-commencing’ endogenous androgen deprivation therapy. After discussion with the endocrine team, careful intermittent testosterone supplementation was undertaken to address his symptoms, with the patient undergoing prostate-specific antigen surveillance. This was felt to be similar to intermittent androgen deprivation therapy in reverse. Here, we review current evidence regarding testosterone therapy in the context of prostate cancer. Level of Evidence: 5

Prostate specific antigen testing as disease surveillance and monitoring five years after definitive therapy for localized prostate cancer.

e17602 Background: The National Comprehensive Cancer Network, in 2007, recommends prostate specific antigen (PSA) testing every 6-12 months for the first 5 years following definitive treatment for localized prostate cancer. We compared guideline-concordant PSA testing, as disease surveillance and monitoring, in African-American (AA) and Caucasian (CA) men 5-years after definitive therapy. Methods: A total of 19,377 CA and 1,995 AA men from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database diagnosed with prostate cancer and received definitive treatments from 2007 through 2016 were included. Multivariate log-binomial regression model were used to examine the effect of demographic and clinical characteristics on the likelihood of not receiving at least one PSA surveillance test annually for the first 5 years following definitive treatment. Results: Overall, receipt of surveillance testing and monitoring was high, with 97% of CA men and 94% of AA men receiving at least one test the first year after treatment and approximately 81% of CA men and 77% of AA men receiving at least one test in the fifth year after treatment. Risk of not receiving a test in AA men declined with time compared to CA men, in the first year (Relative Risk [RR], 1.68, 95% CI, 1.37-2.07) and the fifth year (RR, 1.07, 95% CI, 0.98-1.18) since treatment. Further, non-married men and men with intermediate risk had a higher risk of not receiving a surveillance test. Conclusions: Most men received guideline-concordant PSA testing 5-years after definitive therapy. The decline in PSA surveillance overtime reflects the need for continued long-term survivorship care planning and coordination. [Table: see text]

Association between PSA values and surveillance quality after prostate cancer surgery.

BackgroundAlthough prostate‐specific antigen (PSA) testing is used for prostate cancer detection and posttreatment surveillance, thresholds in these settings differ. The screening cutoff of 4.0 ng/mL may be inappropriately used during postsurgery surveillance, where 0.2 ng/mL is typically used, creating missed opportunities for effective salvage radiation treatment. We performed a study to determine whether guideline concordance with annual postoperative PSA surveillance increases when PSA values exceed 4 ng/mL, which represents a screening threshold that is not relevant after surgery.MethodsWe used US Veterans Health Administration data to perform a retrospective longitudinal cohort study of men diagnosed with nonmetastatic prostate cancer from 2005 to 2008 who underwent radical prostatectomy. We used logistic regression to examine the association between postoperative PSA levels and receipt of an annual PSA test.ResultsAmong 10 400 men and 38 901 person‐years of follow‐up, annual guideline concordance decreased from 95% in year 1 to 79% in year 7. After adjustment, guideline concordance was lower for the youngest and oldest men, Black, and unmarried men. Guideline concordance significantly increased as PSA exceeded 4 ng/mL (adjusted odds ratio 2.20 PSA > 4‐6 ng/mL vs PSA > 1‐4 ng/mL, 95% confidence interval 1.20‐4.03; P = .01).ConclusionsGuideline concordance with prostate cancer surveillance increased when PSA values exceeded 4 ng/mL, suggesting a screening threshold not relevant after prostate cancer surgery, where 0.2 ng/mL is considered treatment failure, is impacting cancer surveillance quality. Clarification of PSA thresholds for early detection vs cancer surveillance, as well as emphasizing adherence for younger and Black men, appears warranted.

Active surveillance for prostate cancer: a systematic review of contemporary worldwide practices

In the last decade, active surveillance (AS) has emerged as an acceptable choice for low-risk prostate cancer (PC), however there is discordance amongst large AS cohort studies with respect to entry and monitoring protocols. We systematically reviewed worldwide AS practices in studies reporting ≥5 years follow-up. We searched PubMed and Medline 2000-now and identified 13 AS cohorts. Three key areas were identified: (I) patient selection; (II) monitoring protocols; (III) triggers for intervention—(I) all studies defined clinically localised PC diagnosis as T2b disease or less and most agreed on prostate-specific antigen (PSA) threshold (<10 µg/L) and Gleason score threshold (3+3). Inconsistency was most notable regarding pathologic factors (e.g., number of positive cores); (II) all agreed on PSA surveillance as crucial for monitoring, and most agreed that confirmatory biopsy was required within 12 months of initiation. No consensus was reached on optimal timing of digital rectal examination (DRE), general health assessment or re-biopsy strategies thereafter; (III) there was no universal agreement for intervention triggers, although Gleason score, number or percentage of positive cancer cores, maximum cancer length (MCL) and PSA doubling time were used by several studies. Some also used imaging or re-biopsy. Despite consistent high progression-free/cancer-free survival and conversion-to-treatment rates, heterogeneity exists amongst these large AS cohorts. Combining existing evidence and gathering more long-term evidence [e.g., the Movember’s Global AS database or additional information on use of magnetic resonance imaging (MRI)] is needed to derive a broadly supported guideline to reduce variation in clinical practice.

The role of the multiparametric MRI in the diagnosis of prostate cancer in biopsy-naïve men.

To review the role of prebiopsy multiparametric MRI in biopsy-naïve men for the detection of clinically significant prostate cancer. Recent level 1 evidence shows that multiparametric MRI has high sensitivity and negative predictive value for the detection of clinically significant prostate cancer in biopsy-naïve men. Concurrent developments include important work in the standardization of MRI reporting. The low specificity and positive predictive value of MRI means that biopsy is still necessary following MRI. MRI-targeted prostate biopsy has emerged as an alternative diagnostic test to transrectal ultrasound guided prostate biopsy, though its exact role in biopsy-naïve men and the optimal technique remain to be defined. There is the potential for MRI to be used as a triage test to allow a proportion of men to avoid biopsy and remain on prostate-specific antigen surveillance. MRI-suspicious areas can be sampled more intensively using MRI-targeted biopsy that can be carried out in a variety of ways. Future work should focus on the cost-effectiveness of introducing a prebiopsy MRI pathway in biopsy-naïve men and addressing the training needs for such a change. VIDEO ABSTRACT: http://links.lww.com/COU/A11.

Metabolic atrophy and 3‐T 1H‐magnetic resonance spectroscopy correlation after radiation therapy for prostate cancer

To correlate 3-T magnetic resonance spectroscopic imaging (MRSI) with prostate-specific antigen (PSA) levels in patients with prostate cancer treated with external beam radiation therapy to assess the potential advantages of MRSI. A total of 50 patients (age range 65-83 years) underwent PSA and MRSI surveillance before and at 3, 6, 12, 18 and 24 months after radiotherapy. Of the 50 patients examined, 13 patients completely responded to therapy showing metabolic atrophy (MA), defined as a choline-plus-creatine/citrate (CC/C) ratio <0.2, at 3 months; in this group none had biochemical relapse (PSA nadir + 2 ng/mL) by the end of the follow-up. Of the 50 patients, 35 showed a partial response to therapy (CC/C ratio between 0.2 and 0.8) at 3 and 6 months and, of these 35 patients, 30 reached MA at 12 months, while five developed a recurrence (CC/C ratio >0.8). Three of those patients with recurrence had a biochemical relapse at 18 months and the other two at 24 months. Two of the 50 patients did not respond to the treatment, showing persistent disease from the 3rd month (CC/C ratio >0.8); one patient had biochemical relapse at 6 and the other at 12 months. MRSI was shown to have a greater potential than PSA level in monitoring patients after radiotherapy, because it anticipates PSA nadir, and biochemical relapse in particular.

The Relationship of the Intensity of Posttreatment Prostate-Specific Antigen Surveillance and Prostate Cancer Outcomes: Results From a Population-Based Cohort

ObjectiveTo determine whether higher intensity of prostate-specific antigen (PSA) surveillance was associated with earlier detection of biochemical recurrence (BCR) or survival. Patients and MethodsWe identified a population-based cohort of 832 men diagnosed with nonmetastatic prostate cancer between January 1, 1995, and July 31, 2006. These men were treated with radical prostatectomy (RP), brachytherapy or external beam radiation therapy (RT), or primary androgen deprivation therapy or chose watchful waiting. To test the associations of intensity in PSA surveillance with study outcomes, we used a 2-year landmark analysis to assess whether the number of PSA tests during the first 2 years after treatment was associated with earlier detection of BCR, prostate cancer–related mortality, and all-cause mortality. We used landmark analysis to assess the association of PSA intensity, adjusting for clinicopathologic covariate, with outcome. ResultsMedian follow-up time for the entire cohort was 6.7 years. Higher Gleason score was the only clinicopathologic variable associated with higher PSA frequency in multivariable analysis for both the RP and RT groups (P value of .001 and .05, respectively). After adjustment for other covariates, the frequency of PSA tests during the first 2 years after RP did not increase the ability to detect BCR (hazard ratio, 1.00; 95% confidence interval, 0.84-1.19) or all-cause mortality (hazard ratio, 0.95; 95% confidence interval, 0.70-1.30) in the landmark analysis. ConclusionHigher intensity of PSA surveillance during the 2 years after RP or RT did not improve earlier detection of BCR or survival. Evidence-based guidelines for PSA surveillance after primary treatment are needed.

Editorial Comment

In the early to mid-2000s, the notion of forgoing treatment for clinically localized prostate cancer gained traction as the “watch and wait” philosophy ceded to a less passive mode of management: “active surveillance.” Active surveillance is predicated on the balance between data suggesting substantial overtreatment in the United States of clinically localized prostate cancer 1 Telesca D. Etzioni R. Gulati R. Estimating lead time and overdiagnosis associated with PSA screening from prostate cancer incidence trends. Biometrics. 2008; 64: 10-19 Crossref PubMed Scopus (91) Google Scholar , 2 Lu-Yao G.L. Albertsen P.C. Moore D.F. et al. Outcomes of localized prostate cancer following conservative management. JAMA. 2009; 302: 1202-1209 Crossref PubMed Scopus (352) Google Scholar and the difficulty disentangling the overdiagnosed cancers from those that are potentially lethal. Under an ideal active surveillance algorithm, the life-threatening cancers would declare themselves at a stage when these cancers remain (assuming they ever were) curable, whereas overdiagnosed cancers persist on a regimen that may spare patients from the quality-of-life burden of curative treatments for clinically localized prostate cancer. We believe, based on practice guidelines, 3 Thompson I. Thrasher J.B. Aus G. et al. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol. 2007; 177: 2106-2131 Abstract Full Text Full Text PDF PubMed Scopus (860) Google Scholar that regular prostate-specific antigen (PSA) testing and consideration of repeat prostate biopsy should comprise most active surveillance regimens. Prostate-specific Antigen Surveillance Among Men With Clinically Localized Prostate Cancer Who Do Not Receive Initial TreatmentUrologyVol. 78Issue 5PreviewTo describe the use and determinants of prostate-specific antigen (PSA) surveillance in a population-based cohort. PSA measurements are an important component of surveillance for men with clinically localized prostate cancer who do not receive initial treatment. Full-Text PDF

Prostate-specific Antigen Surveillance Among Men With Clinically Localized Prostate Cancer Who Do Not Receive Initial Treatment

To describe the use and determinants of prostate-specific antigen (PSA) surveillance in a population-based cohort. PSA measurements are an important component of surveillance for men with clinically localized prostate cancer who do not receive initial treatment. Using the linked Surveillance, Epidemiology, and End Results-Medicare program, we evaluated 7145 men, aged 65-84 years, who had been diagnosed from 1997 to 2002 with American Joint Committee on Cancer, 6th edition, Stage T1-T2, Gleason score ≤7 prostate cancer and received expectant management. For all patients, the Medicare claims were observed until a secondary cancer treatment event, death, or December 31, 2006. We performed multivariable logistic regression analysis to examine the relationship between the primary outcome of annual PSA surveillance and the patient, clinical, and demographic characteristics. Of the men with localized Gleason score ≤7 prostate cancer who did not receive initial treatment, 39% underwent at least annual PSA measurement. On multivariable logistic regression analysis, annual PSA surveillance was positively associated with older age (75-84 vs 65-74 years, odds ratio [OR] 1.37, 95% confidence interval [CI] 1.23-1.52), more comorbidities (OR 3.38, 95% CI 2.91-3.93), and residence in a neighborhood with a greater median income (OR 1.81, 95% CI 1.46-2.25). A lower likelihood of annual PSA surveillance was associated with black race (OR 0.55, 95% CI 0.45-0.67). Most men with localized prostate cancer who forgo initial treatment do not receive annual PSA surveillance. Additional research is necessary to clarify the benefits and harm of increased surveillance among older men and those with medical comorbidities.

Should baseline PSA testing be performed in men aged 40 to detect those aged 50 or less who are at risk of aggressive prostate cancer?

We aimed to evaluate the presenting features and treatment outcome of prostate cancer in men aged <50 years, in a region where prostate specific antigen (PSA) screening is not readily available and most men present with symptoms. We analysed the data of 1 571 men with prostatic adenocarcinoma treated between January 1997 and December 2008 at out institution, a tertiary level public secotr hospital serving a largely indigent population. Statistical analysis was performed using Student's, the Mann-Whitney and Fisher's exact tests where appropriate (p<0.05 accepted as statistically significant). Of 1 571 men, 47 (3%) were aged < 50 years. The group aged <50 years compared with that aged >50 years, had a siginificantly greater proportion with poorly differentiated adenocarcinoma (53%), locally advanced (stage T3-4) tumours (56%), haematogenous metastases (75%), significantly higher serum PSA at diagnosis (mean 621, median 74 ng/ml) and shorter survival. Men aged <50 years presenting with symptoms owing to prostate cancer had significantly higher risk disease, higher mean PSA, and poorer prognosis than men aged >50 years. To diagnose prostate cancer at a potentially curable stage in men aged <50 years, it is necessary to initiate asleine PSA testing at age 40 and 45 years, and to select high-risk men for PSA surveillance in order to diagnose potentially curable cancer in those with a life expectancy >20-25 years.

Is Prostate-Specific Antigen Surveillance Necessary in Men with Benign Prostate Pathology following Radical Cystoprostatectomy for Bladder Cancer?

Background: Radical cystoprostatectomy (RCP) remains the gold standard for the treatment of muscle-invasive bladder cancer. There are limited data regarding the clinical impact and detection of PSA following complete prostatectomy or the need to monitor serum PSA in patients with benign prostate pathology at time of RCP. The purpose of our study was to analyze the postoperative PSA characteristics of men without prostate cancer who underwent a RCP for bladder cancer. Methods: The demographic, clinical and pathologic data were reviewed on 138 men who underwent RCP for bladder cancer from 1994 to 2008. Patients with known or incidentally discovered prostate cancer on final pathology were excluded from this study, and postoperative serum PSA values were reviewed in the remaining men. Results: The median age of the study population was 64 years (range 40–84). At a mean follow-up of 40.7 months, 137 (99.3%) of patients had an undetectable serum PSA. The one (0.7%) case in which serum PSA was not undetectable underwent an apex-sparing prostatectomy at the time of cystectomy. Conclusions: Serum PSA should remain undetectable for men with benign prostate pathology undergoing complete prostatectomy at the time of RCP. Elevated serum PSA following complete RCP in men with bladder cancer and pathologically confirmed benign prostate findings is rare. If the serum PSA is undetectable 3 months after RCP with benign prostate pathology, there is no need for continued PSA monitoring. These data support the notion that potential nonprostatic sources of PSA are clinically insignificant following complete removal of the prostate.

Lifelong Yearly Prostate Specific Antigen Surveillance is Not Necessary for Low Risk Prostate Cancer Treated With Radical Prostatectomy

Many patients undergoing radical prostatectomy in the prostate specific antigen era have a low risk of recurrence. Aggressive postoperative prostate specific antigen surveillance is costly and anxiety provoking. In this study we investigate the need for yearly prostate specific antigen measurements in patients with surgically treated low risk prostate cancer. We identified 2,219 patients who underwent radical prostatectomy between 1994 and 2004 for low risk localized prostate cancer. Low risk was defined as prostate specific antigen less than 10 ng/ml, pathological stage pT2c or less, Gleason score 6 or less, negative lymph nodes and negative surgical margins. Patients who underwent neoadjuvant or adjuvant therapy were excluded from analysis. Biochemical failure was defined as a prostate specific antigen greater than 0.4 ng/ml and prostate specific antigen values less than 0.15 ng/ml were considered undetectable. Biochemical failure rates were calculated according to the duration of the prostate specific antigen-free period after radical prostatectomy. A total of 142 (6.4%) patients experienced biochemical failure during the course of the study. The risk of biochemical failure decreased with increasing duration of the prostate specific antigen-free interval. For example 1, 3 and 5-year biochemical failure rates calculated at surgery were 1.8%, 4.2% and 6.3%, respectively. For patients with undetectable prostate specific antigen measurements 5 years after surgery the 1, 3 and 5-year biochemical failure rates were 0.0%, 0.7% and 1.3%, respectively. In addition, 1-year biochemical failure rates were 0.2%, 0.4%, 0.0% and 0.0% after a prostate specific antigen-free period of 1, 3, 5 and 10 years, respectively. The risk of biochemical failure is inversely proportional to the duration of the prostate specific antigen-free interval after radical prostatectomy in low risk patients. Biochemical failure 1 year after an undetectable prostate specific antigen is uncommon, especially after a prostate specific antigen-free period of 3 years. These data suggest that annual prostate specific antigen measurements are unnecessary, especially after a prostate specific antigen-free interval of 3 years. Prostate specific antigen measurements every 2 years should capture the majority of low risk patients who experience progression.

Analysis of prostate-specific antigen bounce after I 125 permanent seed implant for localised prostate cancer

Background and purpose To report on the incidence of benign prostate-specific antigen bounce following permanent I 125 prostate brachytherapy, to describe the associations in our population and review the relationship of bounce to subsequent biochemical failure. Materials and methods From February 2000 to May 2005, 374 patients with localised prostate cancer were treated with I 125 permanent prostate brachytherapy at a single institution. A prospectively collected database was used to identify cases of prostate-specific antigen (PSA) bounce, defined as a rise of ⩾0.2 ng/ml above an initial PSA nadir with subsequent decline to or below that nadir without treatment. The patients who received neo-adjuvant or adjuvant hormone manipulation were excluded. Biochemical failure was determined using the both the ASTRO consensus definition and Phoenix (nadir +2 ng/mL) definition. Results Two hundred and five patients were identified with a median follow-up of 45 months (24–85). PSA bounce was noted in 79 (37%) men, occurring at a median of 14.8 months (1.7–40.6) following implant. The median peak PSA was 1.8 ng/ml (0.4–7.4) with a bounce magnitude of 0.91 ng/ml (0.2–5.8). When pre- and post-implant factors were assessed for association to bounce, only younger age was statistically significant ( p = 0.002). The threshold for biochemical failure as defined by the ASTRO consensus definition (1997) was met in 4 (5%) patients after experiencing bounce as opposed to 19 (15%) non-bounce patients ( p = 0.01). The threshold for Phoenix (nadir +2 ng/mL) was met in 6 (7.5%) patients following bounce versus 22 (17%) of non-bounce patients ( p = 0.003). Both definitions are prone to false positive calls during bounce. Median PSA velocity during the bounce was 0.08 ng/mL/month (0.02–0.98) and was statistically significantly lower than the median velocity prior to the Phoenix biochemical failure at 0.28 ng/mL/month (0.07–2.04) ( p = 0.0005). Conclusion PSA bounce is a common finding in our population and is associated with a lower rate of subsequent biochemical failure. The noted differences in PSA velocity will require verification in a future analysis to reduce the influence of median follow-up on this finding. Patients should be advised of the potential of bounce in PSA follow-up after permanent I 125 prostate brachytherapy and physicians involved in follow-up of prostate brachytherapy patients should be aware of this phenomenon, allowing them to commit to appropriate PSA surveillance, avoiding the premature and inappropriate initiation of salvage therapy during PSA bounce.

A Prospective, Randomized Trial Comparing Conventional Transurethral Prostate Resection With PlasmaKinetic® Vaporization of the Prostate: Physiological Changes, Early Complications and Long-Term Followup

We compared standard transurethral prostate resection with bipolar PlasmaKinetic prostate vaporization for bladder outflow obstruction using a Gyrus PlasmaKinetic Plasma V bar. A total of 160 men were enrolled in a prospective, randomized trial. Those at higher risk for cancer were excluded by prostate specific antigen and digital rectal examination with or without transrectal ultrasound biopsy. A total of 81 men underwent prostate vaporization and 79 underwent transurethral prostate resection. Preoperative International Prostate Symptom Score and quality of life score, uroflowmetry, post-void residual urine and transrectal ultrasound prostate volume were recorded. Preoperative and postoperative serum hemoglobin, hematocrit and sodium were measured. Perioperative fluid absorption was calculated using weighing on table and blood loss using the Hemocue system. Longer followup of International Prostate Symptom Score and quality of life score, uroflowmetry and post-void residual urine was available in 149 men, including 76 who underwent prostate vaporization and 73 who underwent transurethral prostate resection. Data were analyzed using the 1 or 2-sample t and chi-square tests. The 2 groups were comparable in all preoperative parameters. Perioperative fluid absorption, intraoperative blood loss, preoperative and postoperative serum hematocrit, and sodium changes were not statistically different. Mean resection time was 4 minutes shorter for transurethral prostate resection (28.5 vs 32.6 minutes, p = 0.08). Patients with transurethral prostate resection showed a greater hemoglobin decrease (1.39 vs 0.8 gm/dl, p = 0.002) and required more irrigation postoperatively (28.3 vs 20.4 l, p = 0.001). Four patients with transurethral prostate resection required transfusion compared with none who underwent prostate vaporization. After transurethral prostate resection hospital stay was longer (3.36 vs 3.02 days, p = 0.03). Cancer was detected in 8 patients with transurethral prostate resection (10%), of whom 7 are under prostate specific antigen surveillance and 1 received radical radiotherapy. Mean long-term followup was 258 days (range 82 to 884). Prostate vaporization and transurethral prostate resection were equally effective at followup, as evidenced by changes in maximum urine flow, International Prostate Symptom Score, quality of life score and post-void residual urine. The 2 operations are highly effective in experienced hands. PlasmaKinetic prostate vaporization resulted in less postoperative bleeding and a slightly shorter hospital stay. The lack of a histological specimen with this version of PlasmaKinetic prostate vaporization may mean that clinically significant cancers are missed.