Use Of Prostate-specific Antigen Screening Research Articles

A prospective prostate cancer screening programme for men with pathogenic variants in mismatch repair genes (IMPACT): initial results from an international prospective study.

SummaryBackgroundLynch syndrome is a rare familial cancer syndrome caused by pathogenic variants in the mismatch repair genes MLH1, MSH2, MSH6, or PMS2, that cause predisposition to various cancers, predominantly colorectal and endometrial cancer. Data are emerging that pathogenic variants in mismatch repair genes increase the risk of early-onset aggressive prostate cancer. The IMPACT study is prospectively assessing prostate-specific antigen (PSA) screening in men with germline mismatch repair pathogenic variants. Here, we report the usefulness of PSA screening, prostate cancer incidence, and tumour characteristics after the first screening round in men with and without these germline pathogenic variants.MethodsThe IMPACT study is an international, prospective study. Men aged 40–69 years without a previous prostate cancer diagnosis and with a known germline pathogenic variant in the MLH1, MSH2, or MSH6 gene, and age-matched male controls who tested negative for a familial pathogenic variant in these genes were recruited from 34 genetic and urology clinics in eight countries, and underwent a baseline PSA screening. Men who had a PSA level higher than 3·0 ng/mL were offered a transrectal, ultrasound-guided, prostate biopsy and a histopathological analysis was done. All participants are undergoing a minimum of 5 years' annual screening. The primary endpoint was to determine the incidence, stage, and pathology of screening-detected prostate cancer in carriers of pathogenic variants compared with non-carrier controls. We used Fisher's exact test to compare the number of cases, cancer incidence, and positive predictive values of the PSA cutoff and biopsy between carriers and non-carriers and the differences between disease types (ie, cancer vs no cancer, clinically significant cancer vs no cancer). We assessed screening outcomes and tumour characteristics by pathogenic variant status. Here we present results from the first round of PSA screening in the IMPACT study. This study is registered with ClinicalTrials.gov, NCT00261456, and is now closed to accrual.FindingsBetween Sept 28, 2012, and March 1, 2020, 828 men were recruited (644 carriers of mismatch repair pathogenic variants [204 carriers of MLH1, 305 carriers of MSH2, and 135 carriers of MSH6] and 184 non-carrier controls [65 non-carriers of MLH1, 76 non-carriers of MSH2, and 43 non-carriers of MSH6]), and in order to boost the sample size for the non-carrier control groups, we randomly selected 134 non-carriers from the BRCA1 and BRCA2 cohort of the IMPACT study, who were included in all three non-carrier cohorts. Men were predominantly of European ancestry (899 [93%] of 953 with available data), with a mean age of 52·8 years (SD 8·3). Within the first screening round, 56 (6%) men had a PSA concentration of more than 3·0 ng/mL and 35 (4%) biopsies were done. The overall incidence of prostate cancer was 1·9% (18 of 962; 95% CI 1·1–2·9). The incidence among MSH2 carriers was 4·3% (13 of 305; 95% CI 2·3–7·2), MSH2 non-carrier controls was 0·5% (one of 210; 0·0–2·6), MSH6 carriers was 3·0% (four of 135; 0·8–7·4), and none were detected among the MLH1 carriers, MLH1 non-carrier controls, and MSH6 non-carrier controls. Prostate cancer incidence, using a PSA threshold of higher than 3·0 ng/mL, was higher in MSH2 carriers than in MSH2 non-carrier controls (4·3% vs 0·5%; p=0·011) and MSH6 carriers than MSH6 non-carrier controls (3·0% vs 0%; p=0·034). The overall positive predictive value of biopsy using a PSA threshold of 3·0 ng/mL was 51·4% (95% CI 34·0–68·6), and the overall positive predictive value of a PSA threshold of 3·0 ng/mL was 32·1% (20·3–46·0).InterpretationAfter the first screening round, carriers of MSH2 and MSH6 pathogenic variants had a higher incidence of prostate cancer compared with age-matched non-carrier controls. These findings support the use of targeted PSA screening in these men to identify those with clinically significant prostate cancer. Further annual screening rounds will need to confirm these findings.FundingCancer Research UK, The Ronald and Rita McAulay Foundation, the National Institute for Health Research support to Biomedical Research Centres (The Institute of Cancer Research and Royal Marsden NHS Foundation Trust; Oxford; Manchester and the Cambridge Clinical Research Centre), Mr and Mrs Jack Baker, the Cancer Council of Tasmania, Cancer Australia, Prostate Cancer Foundation of Australia, Cancer Council of Victoria, Cancer Council of South Australia, the Victorian Cancer Agency, Cancer Australia, Prostate Cancer Foundation of Australia, Asociación Española Contra el Cáncer (AECC), the Instituto de Salud Carlos III, Fondo Europeo de Desarrollo Regional (FEDER), the Institut Català de la Salut, Autonomous Government of Catalonia, Fundação para a Ciência e a Tecnologia, National Institutes of Health National Cancer Institute, Swedish Cancer Society, General Hospital in Malmö Foundation for Combating Cancer.

A continuous fall of PSA use for prostate cancer screening among Brazilian doctors since 2001. Good or bad notice?

ABSTRACTPurpose:To evaluate the trend of use of Prostate Specific Antigen (PSA) for screening of prostate cancer (PC) among Brazilian doctors, from the beginning of its regular availability in clinical laboratories.Material and Methods:A serial cross-sectional study was performed using data obtained from a large database between 1997 and 2016. The general PSA screening trend during this period, adjusted for the total number of exams performed in men, was analyzed. Time-series analysis was performed through observation of the general regression curve using the generalized least squares method, and the impact of the recommendations was assessed with autoregressive integrated moving average (ARIMA) models.Results:During the period studied 2,521,383 PSA determinations were done. The age of the participants ranged from 21 to 111 years, with an average of 56.7 ± 22.7 years. The relative number of PSA tests/100.000 exams in males showed a constant reduction since 2001, and this trend was more evident in the group aged 55-69 years. Although statistically significant, the impact of reduced PSA screening after the 2012 USPSTF publication was clinically irrelevant.Conclusions:Our results indicated a continuous reduction in the use of PSA screening over time, regardless of the publication of recommendations or clinical guidelines. The fact that this trend was more pronounced among those with a greater benefit potential (55-69 years), relative to groups with a greater damage potential due to overdiagnosis and overtreatment (aged >74 years and <40 years), is a matter of concern. Follow-up studies of these trends are advisable.

64] The usefulness of prostate-specific antigen screening in men presenting with haematuria in our practice in a District hospital in the UK

ObjectiveTo review the usefulness of prostate-specific antigen (PSA) testing in men presenting to an urgent clinic with haematuria in our practice in a District hospital in the UK.

Impact of numeracy on understanding of prostate cancer risk reduction in PSA screening.

Prostate-specific antigen (PSA) screening for prostate cancer in men of average risk remains controversial. Patients’ ability to incorporate risk reduction data into their decision-making may depend on their numeracy. We assessed the impact of patients’ numeracy on their understanding of the risk reduction benefits of PSA screening. Men attending a general internal medicine clinic were invited to complete a survey. Four versions of the survey each included a three-item numeracy test and PSA risk reduction data, framed one of four ways: absolute (ARR) versus relative risk reduction (RRR), with or without baseline risk (BR). Respondents were asked to adjust their perceived risk of prostate-cancer mortality using the data presented. Accuracy of risk reduction was evaluated relative to how risk data were framed. Among a total of 200 respondents, a majority incorrectly answered one or more of the numeracy items. Overall accuracy of risk adjustment was only 20%. Accuracy varied with data framing: when presented with RRR, respondents were 13% accurate without BR and 31% accurate with BR; when presented with ARR, they were 0% accurate without BR and 35% accurate with BR. Including BR data significantly improved accuracy for both RRR (P = 0.03) and ARR groups (P < 0.01). Accuracy was significantly related to numeracy; numeracy scores of 0, 1, 2, and 3 were associated with accuracy rates of six, five, nine, and 36 percent, respectively (P < 0.01). Overall, numeracy was significantly associated with the accuracy of interpreting quantitative benefits of PSA screening. Alternative methods of communicating risk may facilitate shared decision-making in the use of PSA screening for early detection of prostate cancer.

238 - The use of prostate-specific antigen screening in purchased versus direct care settings: Data from the TRICARE military database

238 - The use of prostate-specific antigen screening in purchased versus direct care settings: Data from the TRICARE military database

National Trends in Prostate Biopsy and Radical Prostatectomy Volumes Following the US Preventive Services Task Force Guidelines Against Prostate-Specific Antigen Screening

Studies demonstrate that use of prostate-specific antigen screening decreased significantly following the US Preventive Services Task Force (USPSTF) recommendation against prostate-specific antigen screening in 2012. To determine downstream effects on practice patterns in prostate cancer diagnosis and treatment following the 2012 USPSTF recommendation. Procedural volumes of certifying and recertifying urologists from 2009 through 2016 were evaluated for variation in prostate biopsy and radical prostatectomy (RP) volume. Trends were confirmed using the New York Statewide Planning and Research Cooperative System and Nationwide Inpatient Sample. The study included a representative sample of urologists across practice settings and nationally representative sample of all RP discharges. We obtained operative case logs from the American Board of Urology and identified urologists performing at least 1 prostate biopsy (n = 5173) or RP (n = 3748), respectively. The 2012 USPSTF recommendation against routine population-wide prostate-specific antigen screening. Change in median biopsy and RP volume per urologist and national procedural volume. Following the USPSTF recommendation, median biopsy volume per urologist decreased from 29 to 21 (interquartile range [IQR}, 12-34; P < .001). After adjusting for physician and practice characteristics, biopsy volume decreased by 28.7% following 2012 (parameter estimate, -0.25; SE, 0.03; P < .001). Similarly, following the USPSTF recommendation, median RP volume per urologist decreased from 7 (IQR, 3-15) to 6 (IQR, 2-12) (P < .001), and in adjusted analyses, RP volume decreased 16.2% (parameter estimate, -0.15; SE, 0.05; P = .003). Following the 2012 USPSTF recommendation, prostate biopsy and RP volumes decreased significantly. A panoramic vantage point is needed to evaluate the long-term consequences of the 2012 USPSTF recommendation.

Randomized trial finds that prostate cancer genetic risk score feedback targets prostate-specific antigen screening among at-risk men.

Prostate-specific antigen (PSA) screening may reduce death due to prostate cancer but leads to the overdiagnosis of many cases of indolent cancer. Targeted use of PSA screening may reduce overdiagnosis. Multimarker genomic testing shows promise for risk assessment and could be used to target PSA screening. To test whether counseling based on the family history (FH) and counseling based on a genetic risk score (GRS) plus FH would differentially affect subsequent PSA screening at 3 months (primary outcome), a randomized trial of FH versus GRS plus FH was conducted with 700 whites aged 40 to 49 years without prior PSA screening. Secondary outcomes included anxiety, recall, physician discussion at 3 months, and PSA screening at 3 years. Pictographs versus numeric presentations of genetic risk were also evaluated. At 3 months, no significant differences were observed in the rates of PSA screening between the FH arm (2.1%) and the GRS-FH arm (4.5% with GRS-FH vs. 2.1% with FH: χ2 = 3.13, P = .077); however, PSA screening rates at 3 months significantly increased with given risk in the GRS-FH arm (P = .013). Similar results were observed for discussions with physicians at 3 months and PSA screening at 3 years. Average anxiety levels decreased after the individual cancer risk was provided (P = .0007), with no differences between groups. Visual presentation by pictographs did not significantly alter comprehension or anxiety. This is likely the first randomized trial of multimarker genomic testing to report genomic targeting of cancer screening. This study found little evidence of concern about excess anxiety or overuse/underuse of PSA screening when multimarker genetic risks were provided to patients. Cancer 2016;122:3564-3575. © 2016 American Cancer Society.

MP25-10 DECLINE IN PROSTATE SPECIFIC ANTIGEN SCREENING AMONG PRIMARY CARE PHYSICIANS IN RESPONSE TO UNITED STATES PREVENTATIVE SERVICES TASK FORCE RECOMMENDATIONS

INTRODUCTION AND OBJECTIVES: The United States Preventative Services Task Force (USPSTF) controversially recommended against prostate specific antigen (PSA) screening in its guideline released in October of 2011. Previous studies of national screening rates have found a significant decrease in PSA screening after the release of the USPSTF recommendations, however these are limited by their reliance on patient self report. The National Ambulatory Medical Care Survey (NAMCS) is a conducted annually by the Centers for Disease Control and Prevention (CDC), and collects data on PSA screening from records of medical visits. In this study, we aim to determine the frequency of PSA testing by primary care physicians before and after release of the USPSTF guidelines. METHODS: NAMCS is based on a sample of visits to nonfederal, office-based physicians. The basic sampling unit for the NAMCS is the physician-patient visit. All analysis was performed in accordance with NCHS recommendations accounting for the complex survey design, and Pearson0s chi-squared test was used for all statistical comparisons. RESULTS: In men over forty seeing their primary care doctor for preventative care, the rate of PSA testing by year is shown in Figure 1. Comparing the years prior to the release of the USPSTF guideline and 2012, the rate of testing decreased from 28.3% (95% CI 25.2% to 31.5%) to 15.6% (95% CI 11.8% to 20.4%, p<0.001). The rate of testing by age is shown in Figure 2. The American Urological Association currently recommends joint decision-making in deciding on screening in men aged 55 to 69. The rate of screening among these men decreased from 33.0% (95% CI 29.4% to 36.8%) in 2002-2010 to 18.7% (95% CI 13.8% to 24.9%) in 2012 (p<0.001). CONCLUSIONS: Office-based prostate cancer screening decreased 45% after the release of the 2012 USPSTF guideline. This report, combined with results from other sources, suggest that the use of PSA screening is rapidly declining in primary care practice. Source of Funding: None

MP79-03 WAG THE DOG?: PSA SCREENING IN KIDNEY TRANSPLANT CANDIDATES

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery I1 Apr 2015MP79-03 WAG THE DOG?: PSA SCREENING IN KIDNEY TRANSPLANT CANDIDATES Daniel Canter, Gerardo Vitiello, Blayne Sayed, Ken Ogan, and Nicole Turgeon Daniel CanterDaniel Canter More articles by this author , Gerardo VitielloGerardo Vitiello More articles by this author , Blayne SayedBlayne Sayed More articles by this author , Ken OganKen Ogan More articles by this author , and Nicole TurgeonNicole Turgeon More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2860AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Screening recommendations for prostate cancer (PC) in the general population are controversial due to the low sensitivity of prostate-specific antigen (PSA) as a marker for PC as well as the indolent nature of PC. The current study aims to determine whether the use of PSA screening in men being evaluated for renal transplantation either delays the time to listing or time to kidney transplantation as well as whether the diagnosis of PC effects the rate of transplantation and graft/patient survival. METHODS A single center retrospective analysis of 3737 patients undergoing kidney transplant evaluation from January 1, 2001 to January 1, 2011 was performed. Men were categorized according to the following American Urological Association (AUA) PSA screening guideline recommendations: Group 1: <55 y.o., Group 2: 55-69 y.o. and Group 3: >69 y.o. Univariate analysis and Cox Proportional Hazards (CPH) identified the independent effect of PSA screening on transplant times. Kaplan Meier survival curves examined the effects of PSA screening and PC on overall patient and graft survivals. RESULTS In total, 1135 patients received kidney transplants (30.4%). PSA screening was performed in 53.9% of Group 1, 81.1% of Group 2, and 83.8% of Group 3. In group 2, the time to transplant was significantly longer in patients having a PSA >4 versus those having a PSA <4 (1355 vs. 853 days; p<0.001). Men with a screening PSA > 4 who never developed prostate cancer were less likely to receive transplants than those patients with a positive screen who develop prostate cancer (18.5 versus 40%, p=0.0025). PC was confirmed in 27% of patients with a PSA >4, and only 24.3% of patients with a PSA >4 received transplants. PSA screening did not impact overall patient survival or graft survivals, though a diagnosis of prostate cancer significantly reduced overall patient survival (HR 2.19 [1.04-4.59]; p=0.0038). CONCLUSIONS A PSA screening level >4 may lower the likelihood of receiving a kidney transplant, however, our data indicate that PSA screening has no effect on overall patient survival. Proper patient selection for PSA screening is essential as delayed transplant times in patients with end-stage renal disease (ESRD) leads to reduced quality of life as well as increase patients' risk of medical and cardiovascular complications while awaiting transplantation. The routine use of PSA screening in renal transplant candidates should reflect a consideration of these risks compared to the biologic phenotype of PC. At the very least, PC screening in the renal transplant population should be more in line with recent recommendations for the general population. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1011 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Canter More articles by this author Gerardo Vitiello More articles by this author Blayne Sayed More articles by this author Ken Ogan More articles by this author Nicole Turgeon More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Abstract B68: Men at high risk for prostate cancer and the prostate-specific antigen (PSA) test: Uptake levels and physician recommendations

Abstract Introduction: The Prostate-Specific Antigen (PSA) is a protein secreted by the cells of the prostate gland. Abnormalities in the prostate, such as cancer, can lead to an increase in PSA blood levels. The PSA test was developed for early detection of prostate cancer. Recently, the U.S. Preventive Services Task Force (USPSTF) updated their original 2008 recommendation against the use of PSA screening for men 75 years and older to include men in the general U.S. population of all ages [5]. The arguments made by the USPSTF apply to the general population with average risk, as opposed to men who have increased risk, such as men with the BRCA 1 or 2 mutations. The PSA test may have benefits of early detection of prostate cancer among this population. This study defines ‘high risk’ men as those who had their blood drawn by a nurse or healthcare professional to see if they carried a gene mutation that may confer increased risk for hereditary cancer and aims to investigate the utilization levels of the PSA test among these high risk men and if the test was recommended to them by their physicians. Methods: Data were gathered from a subset of a survey intended to explore the perceptions and attitudes toward Preimplantation Genetic Diagnosis (PGD) among males who either carry a BRCA mutation or had partners or immediate relatives who had a BRCA mutation [14]. This study focused on analyzing demographics, clinical characteristics, PSA test uptake and physician recommendations. The data were separated into categories of men who indicated that they had a genetic test for hereditary cancer in the past (n=64), and those who had not (n=164). The men who answered ‘yes’ to having had a genetic test in the past were considered high-risk for the purpose of this study. Results: 58.7% of high-risk men were recommended for the PSA test by their doctor or healthcare provider, while 31.7% had not received a recommendation. Of those men not recommended for a PSA test, 20.0% tested positive for a gene that may put them at increased risk for hereditary cancer. The investigation also revealed that 50.79% of high-risk men utilized the PSA test while 46.03% did not. Among men who did not take the PSA test, 17.2% tested positive for a gene that may put them at increased risk for hereditary cancer. Conclusion: The results of this study add to the argument that although the PSA test is an effective long-term diagnostic tool, it is only being utilized by about 50% of men who meet the criteria for being at high-risk for developing prostate cancer and physicians are only recommending about 59% of these high-risk men. Physicians should be encouraged to pay close attention to men who show signs of increased hereditary risk and recommend them for long-term PSA monitoring and better efforts should be made to educate the high risk community of men about the benefits of non-invasive PSA monitoring. Citation Format: Meshka Anderson, Gwendolyn Quinn, Susan Vadaparampil. Men at high risk for prostate cancer and the prostate-specific antigen (PSA) test: Uptake levels and physician recommendations. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B68. doi:10.1158/1538-7755.DISP13-B68

Risk assessment to guide prostate cancer screening decisions: a cost‐effectiveness analysis

To apply the most recent evidence from randomised trials of prostate-specific antigen (PSA) screening and explore the potential value of risk assessments to guide the use of PSA screening in practice. A decision model that incorporated a Markov process was developed in 2012 to estimate the net benefit and cost of PSA screening versus no screening as a function of baseline risk. Quality-adjusted life-2013s (QALYs) and costs. The harms of screening outweighed the benefits under a number of plausible scenarios. Conclusions were sensitive to the estimated quality-of-life impacts of prostate cancer treatment as well as the incidence of cancers not detected by screening tests (poorer prognosis) and those that were detected by screening tests (better prognosis). The base-case incremental cost-effectiveness ratio of PSA screening was $168,611 per QALY for men with average risk, $73,452 per QALY for men with two times the average risk, and $22,938 [corrected] per QALY for men with five times the average risk. PSA screening was not found to be cost-effective for men at an average-to-high risk of prostate cancer, but may be cost-effective for men at very high risk. Inexpensive approaches for identifying men at very high risk are needed, as is further research on the size of clinical benefit of early detection in this population. The potential for the costs of risk assessment to be offset by reduced costs of PSA screening also warrants investigation.

Missing the Mark on Prostate-Specific Antigen Screening

THE US PREVENTIVE SERVICES TASK FORCE RECENTLY issued a draft recommendation against prostatespecific antigen (PSA) screening for prostate cancer. After performing a rigorous review of the relevant empirical literature, the task force concluded with “moderate certainty” that the harms of PSA-based detection (eg, biopsy-related complications) and early intervention (eg, incontinence, erectile dysfunction) exceed the potential benefits. For this reason, the task force now proposes discouraging PSA screening among men who are free of symptoms suspicious for prostate cancer. Most clinicians are aware that PSA is an imperfect tool for the early detection of prostate cancer. First, rather than being focused on patients most likely to benefit from early detection, the use of PSA as a screening test is often undiscerning. Second, PSA-based screening can be inconclusive. As a consequence, for some patients this process can lead to a cycle of repeated venipuncture and biopsy, as well as psychological distress often referred to as “PSA anxiety.” Third, there can be collateral harm to patients in whom PSA screening detects a cancer that was never destined to cause death or morbidity. Fourth, the adverse effects of prostate cancer therapies remain too high, further justifying concerns about the balance of benefits and harms associated with PSA-based screening and early intervention. Even though the process undertaken by the US Preventive Services Task Force was rigorous and these issues were considered, it seems that their recommendations still miss the mark. Over the last 2 decades, and concurrent with the dissemination of PSA screening, there has been a significant decline in prostate cancer–specific mortality in the United States. However, this advance apparently was barely recognized in the deliberations and communications from the task force. This well-established epidemiological trend is difficult, if not impossible, to explain without accepting that early detection strategies built around PSA screening have allowed the identification and successful treatment of patients who would otherwise have died of biologically aggressive, clinically significant prostate cancers. Current evidence suggests that younger men (ie, 70 years) and those with higher-grade cancers benefit from PSA screening and early intervention. Two screening trials reviewed by the task force demonstrated a small—but significant—survival benefit associated with screening for men younger than age 70 years. In contrast, the United States Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial showed no mortality benefits from PSA screening. However, PSA testing in the study’s usual care group was quite high (up to 52%), raising concerns about the study’s ability to answer the question of interest. In terms of treatment, the only trial deemed of “good quality” by the US Preventive Services Task Force (ie, the Scandinavian Prostate Cancer Study Group No. 4) showed that—with 15 years of follow-up—prostate cancer–specific mortality and allcause mortality were 38% and 25% lower, respectively, among men treated surgically compared with men managed with watchful waiting. Subgroup analyses suggested that the survival benefits were greatest for men aged 65 years or younger. In addition, even the limited data currently available from the Prostate Cancer Intervention Versus Observation Trial, portrayed by the task force as a largely negative study, demonstrate a signal favoring treatment among men with higher-risk cancers. So, for PSA screening, is the glass half empty or half full? The answer may depend on clinical experience. Many clinicians involved in the care of men living with and dying of prostate cancer may consider that the data reviewed by the task force reveal potentially meaningful survival benefits for younger men, for those whose PSA level or Gleason score indicate a higher-risk cancer, or both groups (collectively representing tens of thousands of men diagnosed with prostate cancer each year in the United States). Accordingly, the US Preventive Services Task Force recommendation discouraging the use of PSA screening, however well-intentioned, cannot go uncontested. By emphasizing the centrality of avoiding harms associated with detection and treatment (without question a laudable goal), members of the task force—none of whom were urologists, medical oncologists, or radiation therapists—are in es-

The Prostate-Specific Antigen Screening Conundrum: Examining the Evidence

To review the current guidelines/recommendations and the state of evidence regarding prostate-specific antigen (PSA) screening. Nursing and medical literature, published guidelines, and Cochrane Systematic Reviews. Very limited evidence exists to support the widespread use of PSA screening among asymptomatic men. Some evidence exists to support its use among men in moderate- to high-risk groups. No evidence supports its use among men with life expectancies of less than 10 years. Multiple guidelines and recommendations exist regarding PSA screening, and not all are in agreement. Nurses must be cognizant of the available scientific evidence upon which guidelines are based and the strength of this evidence as they apply findings in their teaching. Evaluation and application of scientific evidence facilitates informed patient/family decision-making.

Prostate cancer: an emerging threat to the health of aging men in Asia

The aim of this study was to determine and examine the possible reasons for the difference in prostate cancer incidence between Asian men and North American men by literature review. Data regarding cancer incidence and mortality were obtained from the database of the International Agency for Research on Cancer (IARC). A literature review was conducted by studying related articles published in peer-reviewed journals such as the The New England Journal of Medicine, Journal of Clinical Oncology, A Cancer Journal for Clinicians and Asian Journal of Andrology. To evaluate the early diagnosis and survival rates, the mortality-to-incidence rate ratio (MR/IR) was calculated from the IARC data. By comparing prostate cancer data between Asian men and North American men, we found that differences in the incidence rate and MR/IR could be attributed largely to a lack of annual prostate cancer screening with serum prostate-specific antigen (PSA) in most Asian countries. It is likely that PSA screening also contributes significantly to the differences in prostate cancer mortality rates. Prostate cancer has the highest incidence rate among five common malignancies in Asian Americans. However, the MR/IR ratio of prostate cancer is the lowest among cancers. These data seem to further support the usefulness of PSA screening, even though the percentage of low risk cancers is greater in prostate cancer than in other cancers. The low incidence rate of prostate cancer does not reflect the actual statistics of this disease in Asia. The data from limited institutions in many Asian countries seem to bias the true incidence and mortality rates. To improve this situation, incorporating PSA screening for prostate cancer, as well as constructing a nationwide cancer registration system, will be helpful.

CHANGING APPROACH TO THE PROSTATE AS THE WAY OF NERVE-SPARING EFFECT IMPROVEMENT IN PATIENTS WITH LAPAROSCOPIC PROSTATECTOMY

The use of prostatespecific antigen screening made it possible to detect an earlystage prostate cancer in young men in which nervesparing radical prostatectomy with preservation of erectile function could be performed. Laparoscopic radical prostatectomy (LRPE) is preferred as a nervesparing technique in the treatment of prostate cancer. During the last 2 years 19 patients underwent the modified Brussels technique transperitoneal LRPE, (extrafascial prostatectomy – 17, interfascial – 2). The average period of observation was 10.3 months. 13 of 14 patients were observated more than 6 months. In this group all patients achieved a complete continence, one of the patients remained urine leak with no more than 1 strip a day. Brussels technique provides better control of neurovascular fibers in the seminal vesicles during radical prostatectomy. Posterior approach to the prostate gland should be avoided in the nervesparing LRPE.

Pentafecta: A New Concept for Reporting Outcomes of Robot-Assisted Laparoscopic Radical Prostatectomy

BackgroundWidespread use of prostate-specific antigen screening has resulted in younger and healthier men being diagnosed with prostate cancer. Their demands and expectations of surgical intervention are much higher and cannot be adequately addressed with the classic trifecta outcome measures. ObjectiveA new and more comprehensive method for reporting outcomes after radical prostatectomy, the pentafecta, is proposed. Design, setting, and participantsFrom January 2008 through September 2009, details of 1111 consecutive patients who underwent robot-assisted radical prostatectomy performed by a single surgeon were retrospectively analyzed. Of 626 potent men, 332 who underwent bilateral nerve sparing and who had 1 yr of follow-up were included in the study group. MeasurementsIn addition to the traditional trifecta outcomes, two perioperative variables were included in the pentafecta: no postoperative complications and negative surgical margins. Patients who attained the trifecta and concurrently the two additional outcomes were considered as having achieved the pentafecta. A logistic regression model was created to evaluate independent factors for achieving the pentafecta. Results and limitationsContinence, potency, biochemical recurrence–free survival, and trifecta rates at 12 mo were 96.4%, 89.8%, 96.4%, and 83.1%, respectively. With regard to the perioperative outcomes, 93.4% had no postoperative complication and 90.7% had negative surgical margins. The pentafecta rate at 12 mo was 70.8%. On multivariable analysis, patient age (p=0.001) was confirmed as the only factor independently associated with the pentafecta. ConclusionsA more comprehensive approach for reporting prostate surgery outcomes, the pentafecta, is being proposed. We believe that pentafecta outcomes more accurately represent patients’ expectations after minimally invasive surgery for prostate cancer. This approach may be beneficial and may be used when counseling patients with clinically localized disease.

Comorbidity and mortality results from a randomized prostate cancer screening trial.

Estimates of prostate cancer-specific mortality (PCSM) were similar for men randomly assigned to intervention compared with usual care on the Prostate, Lung, Colorectal and Ovarian PC screening study. However, results analyzed by comorbidity strata remain unknown. Between 1993 and 2001, of 76,693 men who were randomly assigned to usual care or intervention at 10 US centers, 73,378 (96%) completed a questionnaire that inquired about comorbidity and prostate-specific antigen (PSA) testing before random assignment. Fine and Gray's multivariable analysis was performed to assess whether the randomized screening arm was associated with the risk of PCSM in men with no or minimal versus at least one significant comorbidity, adjusting for age and prerandomization PSA testing. After 10 years of follow-up, 9,565 deaths occurred, 164 from PC. A significant decrease in the risk of PCSM (22 v 38 deaths; adjusted hazard ratio [AHR], 0.56; 95% CI, 0.33 to 0.95; P = .03) was observed in men with no or minimal comorbidity randomly assigned to intervention versus usual care, and the additional number needed to treat to prevent one PC death at 10 years was five. Among men with at least one significant comorbidity, those randomly assigned to intervention versus usual care did not have a decreased risk of PCSM (62 v 42 deaths; AHR, 1.43; 95% CI, 0.96 to 2.11; P = .08). Selective use of PSA screening for men in good health appears to reduce the risk of PCSM with minimal overtreatment.

How Can Rates of Prostate‐Specific Antigen Screening Be Reduced in Men Aged 80 and Older?

How Can Rates of Prostate‐Specific Antigen Screening Be Reduced in Men Aged 80 and Older?

Duration of Androgen Suppression in Prostate Cancer

To the Editor: In the trial conducted by Bolla et al. (June 11 issue), 1 more than 70% of the patients had clinical T3 disease, and the median level of prostate-specific antigen (PSA) in patients who underwent randomization was 18.8 ng per milliliter, with a range of up to 159.2. Furthermore, about 20% of the patients presented with Gleason scores of 5 or less, suggesting that these tumors were downgraded as compared with current trends in diagnosis. 2 Since bone scans were not mandated as part of the study, a clinically significant number of patients were likely to have had metastatic disease at presentation. The study, therefore, has limited applicability for most patients whose disease is diagnosed with the use of PSA screening. For patients with an intermediate risk of disease as defined by D’Amico et al., 3 short-term androgen suppression should not be considered inferior to long-term treatment.

Bladder Neck Involvement as pT4 Disease in Prostate Cancer: Implications for Prognosis and Patient Surveillance

Since the use of prostate-specific antigen screening has become widespread, prostate cancer at clinical T4 stage has become rare. Most bladder invasion is actually detected on radical prostatectomy specimens as a microscopic bladder neck involvement (BNI). The 2002 TNM classification system classified prostate cancer with BNI within a unified pT4 category, and rendered it equivalent to invasion into pelvic wall musculature or external sphincter. This decision is controversial. Various series have studied the clinical relevance and the impact of BNI on prognosis. Our evidence-based review provides support to the assignment of BNI within the subset of pT3 stage, and suggests that further improvement of the actual TNM staging system should be considered. However, BNI remains strongly associated with adverse pathology and should be regarded as a factor that worsens the prognosis of the underlying tumor stage.