Faculty Bibliography

CONTEXT: Although prostate cancer (PCa) screening reduces the incidence of advanced disease and mortality, trade-offs include overdiagnosis and resultant overtreatment. OBJECTIVE: To review primary data on PCa overdiagnosis and overtreatment. EVIDENCE ACQUISITION: Electronic searches were conducted in Cochrane Central Register of Controlled Trials, PubMed, and Embase from inception to July 2013 for original articles on PCa overdiagnosis and overtreatment. Supplemental articles were identified through hand searches. EVIDENCE SYNTHESIS: The lead-time and excess-incidence approaches are the main ways used to estimate overdiagnosis in epidemiological studies, with estimates varying widely. The estimated number of PCa cases needed to be diagnosed to save a life has ranged from 48 down to 5 with increasing follow-up. In clinical studies, generally lower rates of overdiagnosis have been reported based on the frequency of low-grade minimal tumors at radical prostatectomy (1.7-46.8%). Autopsy studies have reported PCa in 18.5-38.5%, although not all are low grade or low volume. Factors influencing overdiagnosis include the study population, screening protocol, and background incidence, limiting generalizability between settings. Reported rates of overtreatment vary widely in the literature, although contemporary international studies suggest increasing use of conservative management. CONCLUSIONS: Epidemiological, clinical, and autopsy studies have been used to examine PCa overdiagnosis, with estimates ranging widely from 1.7% to 67%. Correspondingly, estimates of overtreatment vary widely based on patient features and may be declining internationally. Careful patient selection for screening and reducing overtreatment are important to preserve the benefits and reduce the downstream harms of prostate-specific antigen testing. Because all of these estimates are extremely population and context specific, this must be considered when using these data to inform policy. PATIENT SUMMARY: Screening reduces spread and death from prostate cancer (PCa) but overdiagnoses some low-risk tumors that may not have caused harm. Because treatment has potential side effects, it is critical that not all patients with PCa receive aggressive treatment.

PURPOSE: Genome-wide association studies have identified an increasing number of single nucleotide polymorphisms (SNPs) associated with prostate cancer risk. Some of these same genetic variants are also associated with serum PSA levels and lower urinary tract symptoms, raising the question whether the SNPs are truly biomarkers for prostate cancer or simply lead to detection bias. We therefore sought to determine whether the prostate cancer risk SNPs are more strongly associated with tumor volume or prostate volume. MATERIALS AND METHODS: The genotypes of 38 validated prostate cancer risk SNPs were determined in 1,321 Caucasian men who underwent radical prostatectomy. Univariate and multivariate analyses were performed to compare the relationship between SNP frequency, total prostate volume and tumor volume. RESULTS: On multivariate analysis, 2 SNPs on chromosome 8q24, rs16901979 (A) (p=0.01) and rs6983267 (G) (p=0.02), were significantly associated with increased tumor volume. In contrast, rs17632542 (T) (p=0.02), near the PSA gene on 19q13, was associated with significantly lower tumor volume, and rs10788160 (A) (p=0.01) on 10q26 was associated with a significantly larger prostate volume. CONCLUSIONS: Analyses of 38 prostate cancer risk SNPs demonstrates a significant association between several SNPs on chromosome 8q24 and increased tumor volume but not prostate volume, suggesting they are bona fide markers for prostate cancer susceptibility and possibly more aggressive disease. Meanwhile, other "prostate cancer risk SNPs" are associated with PSA levels and either increased prostate volume or decreased tumor volume, suggesting a detection bias due to their phenotypic influence.

OBJECTIVE: The use of social media in medicine has greatly expanded in recent years The objective of this study was to characterize the use of social media among members of the American Urological Association (AUA) PATIENTS AND METHODS: In December 2012-January 2013, the AUA emailed a survey with 34 questions on social media use to 2000 randomly selected urologists and 2047 resident/fellow members Additional data was collected from Symplur analytics on social media utilization surrounding the AUA annual meeting in May 2013 RESULTS: A total of 382 (9.4%) surveys were completed, indicating 74% of responders had an online social media account The most commonly used social media platforms were Facebook (93%), followed in descending order by LinkedIn (46%), Twitter (36%) and Google+ (26%) Age younger than 40 was an important predictor of social media use (83% vs. 56%), with greater uptake among residents/fellows compared to attending (86% vs. 66%) Only 28% of respondents used social media partly or entirely for professional purposes During the AUA 2013 meeting, there were >5,000 tweets from >600 distinct contributors. CONCLUSION: As of early 2013, among respondents to an email survey, most urologists and urology trainees used some form of social media, and its use in urology conferences has greatly expanded.

A major focus in urologic research is the identification of new biomarkers with improved specificity for clinically-significant prostate cancer. A promising new test based on prostate-specific antigen (PSA) is called the Prostate Health Index (PHI), which has recently been approved in the United States, Europe and Australia. PHI is a mathematical formula that combines total PSA, free PSA and [-2] proPSA. Numerous international studies have consistently shown that PHI outperforms its individual components for the prediction of overall and high-grade prostate cancer on biopsy. PHI also predicts the likelihood of progression during active surveillance, providing another noninvasive modality to potentially select and monitor this patient population. This article reviews the evidence on this new blood test with significant promise for both prostate cancer screening and treatment decision-making.

PURPOSE: Approximately a third of prostate cancer cases with a Gleason score of 6 are upgraded at radical prostatectomy. We studied trends and predictors of upgrading and up staging among men with Gleason 6 prostate cancer who were potential candidates for active surveillance in a population based cohort. MATERIALS AND METHODS: From 2007 to 2011, 13,159 men were diagnosed with Gleason 6, clinical stage T1c/T2 prostate cancer in the NPCR (National Prostate Cancer Register of Sweden). Of these men 4,500 underwent radical prostatectomy, including 2,205 with data on the extent of prostate cancer in the biopsy cores. Logistic regression was used to examine variables associated with adverse pathology (defined as upgrading to Gleason 7 or greater, or up staging to pT3 or greater) in the full group and in potential candidates for active surveillance using 6 current published protocols. RESULTS: Among Swedish men with clinically localized Gleason 6 prostate cancer approximately 50% had adverse pathology at radical prostatectomy. Of the men who met the study inclusion criteria of 6 different active surveillance protocols, adverse pathology was present in 33% to 45%. Predictors of adverse pathology were older age, higher prostate specific antigen, prostate specific antigen density greater than 0.15 ng/ml/cm(3), palpable disease and extent of cancer greater than 4 mm on biopsy. Larger prostate volume had an inverse relationship with adverse pathology. CONCLUSIONS: More than a third of men meeting the most stringent active surveillance criteria had adverse pathology at radical prostatectomy in this population based cohort. Active surveillance programs should consider prostate specific antigen density and extent of cancer on biopsy for patient selection.