Faculty Bibliography

Screening and treatment of prostate cancer remain controversial, particularly for elderly men. Since the previous United States Preventive Services Task Force recommendation in 2008 against prostate-specific antigen (PSA) screening after age 75 years, there has not been a substantial reduction in the frequency of PSA testing in this age group. A substantial proportion of elderly men are overdiagnosed and overtreated. On the other hand, men aged >75 years have more aggressive disease. Although screening has questionable benefit for elderly men with significant comorbidities, healthy men >75 years may benefit from definitive therapy. This review discusses prostate cancer screening and management decisions for elderly men, including the use of nomograms and predictive tools for life expectancy. 2013 Springer Science+Business Media New York (outside the USA)

BACKGROUND: Transrectal prostate needle biopsy (PNB) is a standard procedure for the diagnosis of prostate cancer. We recently found an increasing frequency of hospitalization with infectious complications associated with PNB over time. OBJECTIVE: To perform an updated analysis of overall complication rates in a large screening population over the past 18 years and to examine possible predictors of complications on initial PNB. DESIGN, SETTING AND PARTICIPANTS: From 1993-2011, 7216 men underwent initial lateralized sextant PNB in European Randomized Study of Screening for Prostate Cancer (ERSPC) Rotterdam. After 2 weeks a questionnaire was administered to 6962 men regarding PNB-related complications. Outcome Measurements & Statistical Analysis: Overall complication rates as well as specific complications (hematuria for >3 days, hematospermia, significant pain after biopsy, fever, and hospitalizations) were prospectively recorded. Multivariable logistic regression models were performed to assess the relationship between age, comorbidities, and prostate volume with specific complications. RESULTS AND LIMITATIONS: A total of 4674 (67.1%) men reported any sequelae after initial PNB, with hematospermia as the most frequent (53.8%), followed by hematuria (24.3%). Significant pain (4.8%), fever (4.1%), and hospital admission (0.7%) were reported less frequently. Hematospermia was significantly more likely in younger men with fewer comorbidities and smaller prostate volume; whereas hematuria was significantly more frequent among men with increasing comorbidities and prostate volume. In addition, pain was inversely associated with age and was also reported less frequently during later years of biopsy. Limitations of our study include the use of sextant biopsies and a relatively healthy population, while strengths include the large sample size and data on patient-specific covariates. CONCLUSION: Many men experience minor complications after initial PNB, although the frequency of specific complications such as hematospermia and hematuria differed based upon factors such as prostate volume and comorbidities. Overall, these data are useful to counsel patients who are undergoing their first PNB on the frequency of complications in a screening population.

Study Type--Therapy (cohort) Level of Evidence 2b. What's known on the subject? and What does the study add? Radical prostatectomy was previously shown to improve long-term outcomes among men with clinically-detected prostate cancer. Our data suggests that radical prostatectomy is also associated with improved outcomes in men with screen-detected prostate cancer. OBJECTIVE: * To examine the long-term outcomes of radical prostatectomy (RP) among men diagnosed with prostate cancer from the screening and control arms of the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer (ERSPC). PATIENTS AND METHODS: * Among 42,376 men randomised during the period of the first round of the trial (1993-1999), 1151 and 210 in the screening and control arms were diagnosed with prostate cancer, respectively. * Of these men, 420 (36.5%) screen-detected and 54 (25.7%) controls underwent RP with long-term follow-up data (median follow-up 9.9 years). * Progression-free (PFS), metastasis-free (MFS) and cancer-specific survival (CSS) rates were examined, and multivariable Cox proportional hazards models were used to determine whether screen-detected (vs control) was associated with RP outcomes after adjusting for standard predictors. RESULTS: * RP cases from the screening and control arms had statistically similar clinical stage and biopsy Gleason score, although screen-detected cases had significantly lower prostate-specific antigen (PSA) levels at diagnosis. * Men from the screening arm had a significantly higher PFS (P = 0.003), MFS (P < 0.001) and CSS (P = 0.048). * In multivariable models adjusting for age, PSA level, clinical stage, and biopsy Gleason score, the screening group had a significantly lower risk of biochemical recurrence (hazard ratio [HR] 0.43, 95% confidence interval [CI] 0.23-0.83, P = 0.011) and metastasis (HR 0.18, 95% CI 0.06-0.59, P = 0.005). * Additionally adjusting for tumour volume and other RP pathology features, there was no longer a significant difference in biochemical recurrence between the screening and control arms. * Limitations of the present study include lead-time bias and non-randomised treatment selection. CONCLUSIONS: * After RP, screen-detected cases had significantly improved PFS, MFS and CSS compared with controls within the available follow-up time. * The screening arm remained significantly associated with lower rates of biochemical recurrence and metastasis after adjusting for other preoperative variables. * However, considering also RP pathology, the improved outcomes in the screening group appeared to be mediated by a significantly lower tumour volume.