Initial management of low‐risk localized prostate cancer in the UK: analysis of the British Association of Urological Surgeons Cancer Registry

Study Type – Therapy (outcomes research)
Level of Evidence 2c

OBJECTIVE

To assess the patterns of care for low‐risk localized prostate cancer. Management of this condition is highly controversial, with a range of treatment options, but there are no published UK data.

METHODS

Data from the British Association of Urological Surgeons (BAUS) Cancer Registry were linked to the UK Association of Cancer registries postcode directory. The demographic and clinical characteristics, and the initial management of men diagnosed with low‐risk localized prostate cancer in the UK between 2000 and 2006 were analysed.

RESULTS

In all, 43 322 cases of localized prostate cancer were recorded in the BAUS Registry between 2000 and 2006, of which 8861 (20%) met the criteria for low‐risk disease. The proportion classified as low risk ranged from 16% in 2000 to 21% in 2006. The proportion of men with low‐risk disease opting for ‘watchful waiting’ increased from 0% to 39% over the same period. Treatment choice was associated with socio‐economic status. For example, radical prostatectomy was chosen by 34% of patients in the most affluent quintile, compared with 19% in the most deprived quintile (P= 0.01).

CONCLUSION

The management of low‐risk localized prostate cancer in the UK has changed markedly in recent years, and contrasts with that in the USA. The association observed between socio‐economic status and choice of treatment deserves further study.     

Management of Patients with Advanced Prostate Cancer: Report of the Advanced Prostate Cancer Consensus Conference 2019

BackgroundInnovations in treatments, imaging, and molecular characterisation in advanced prostate cancer have improved outcomes, but there are still many aspects of management that lack high-level evidence to inform clinical practice. The Advanced Prostate Cancer Consensus Conference (APCCC) 2019 addressed some of these topics to supplement guidelines that are based on level 1 evidence.ObjectiveTo present the results from the APCCC 2019.Design, setting, and participantsSimilar to prior conferences, experts identified 10 important areas of controversy regarding the management of advanced prostate cancer: locally advanced disease, biochemical recurrence after local therapy, treating the primary tumour in the metastatic setting, metastatic hormone-sensitive/naïve prostate cancer, nonmetastatic castration-resistant prostate cancer, metastatic castration-resistant prostate cancer, bone health and bone metastases, molecular characterisation of tissue and blood, inter- and intrapatient heterogeneity, and adverse effects of hormonal therapy and their management. A panel of 72 international prostate cancer experts developed the programme and the consensus questions.Outcome measurements and statistical analysisThe panel voted publicly but anonymously on 123 predefined questions, which were developed by both voting and nonvoting panel members prior to the conference following a modified Delphi process.Results and limitationsPanellists voted based on their opinions rather than a standard literature review or formal meta-analysis. The answer options for the consensus questions had varying degrees of support by the panel, as reflected in this article and the detailed voting results reported in the Supplementary material.ConclusionsThese voting results from a panel of prostate cancer experts can help clinicians and patients navigate controversial areas of advanced prostate management for which high-level evidence is sparse. However, diagnostic and treatment decisions should always be individualised based on patient-specific factors, such as disease extent and location, prior lines of therapy, comorbidities, and treatment preferences, together with current and emerging clinical evidence and logistic and economic constraints. Clinical trial enrolment for men with advanced prostate cancer should be strongly encouraged. Importantly, APCCC 2019 once again identified important questions that merit assessment in specifically designed trials.Patient summaryThe Advanced Prostate Cancer Consensus Conference provides a forum to discuss and debate current diagnostic and treatment options for patients with advanced prostate cancer. The conference, which has been held three times since 2015, aims to share the knowledge of world experts in prostate cancer management with health care providers worldwide. At the end of the conference, an expert panel discusses and votes on predefined consensus questions that target the most clinically relevant areas of advanced prostate cancer treatment. The results of the voting provide a practical guide to help clinicians discuss therapeutic options with patients as part of shared and multidisciplinary decision making.     

Non-systematic screening for prostate cancer in Sweden--survey from the National Prostate Cancer Registry

OBJECTIVE: The large increase in the incidence of prostate cancer is largely due to testing of serum levels of prostate-specific antigen (PSA). Little is known about how PSA testing is used in clinical practice outside of screening programmes. Essentially, PSA can be used in the health check-ups of men without symptoms as a form of non-systematic screening or in the work-up of symptomatic patients. The aim of this study was to investigate the cause of initiating a work-up leading to a diagnosis of prostate cancer, with emphasis on T1c tumours. MATERIAL AND METHODS: Data on the cause of initiation of work-up leading to a diagnosis of prostate cancer were retrieved from the National Prostate Cancer Registry for 6361 incident cases in tumour category T1c and local stages T2, T3 and T4 registered in Sweden in 2000. RESULTS: For 1496 cases in tumour category T1c (non-palpable tumours detected during work-up of elevated PSA), the cause of PSA testing was health check-ups in 32% of cases, work-up of symptoms suspected to emanate from the prostate in 51% and other causes/not reported in 17%. For all stages combined, the cause of initiation of the diagnostic work-up was health check-ups in 18% of cases, symptoms in 68% and other causes/not reported in 14%. CONCLUSION: Non-systematic screening using PSA testing has been introduced in Sweden. However, prostate cancer is still most commonly diagnosed during the work-up of symptomatic patients.     

Locally advanced prostate cancer: the role of surgical management

Among the heterogeneous population of patients with prostate cancer, a high‐risk group with locally advanced prostate cancer (LAPC) present a diagnostic and therapeutic dilemma. Although the incidence of LAPC has decreased with screening since the introduction of prostate‐specific antigen (PSA) testing, significantly many patients are still diagnosed with LAPC. These patients are by definition at higher risk of metastatic disease and worse outcomes. The role of radical prostatectomy (RP) in this population has been debated, as the combination of radiotherapy and hormonal therapy is becoming used more frequently for LAPC. Unfortunately, the clinical staging and evaluation of LAPC is a challenge that results in possibly understaging or overstaging these patients. This further complicates therapeutic decision‐making, and as a result no established standard treatment has been proposed. Like other patients with prostate cancer, individualized therapeutic choices are essential and depend on a multitude of factors. Herein we examine the role of RP for managing LAPC and attempt to emphasize how the risk of distant disease and difficulty with clinical staging might favour incorporating a surgical approach as part of the therapy for patients with LAPC.     

雄激素非依赖性前列腺癌的治疗进展

前列腺癌是男性泌尿生殖系常见的恶性肿瘤之一,在我国发病率虽较低,但近年来随着人口老龄化及生活条件的改善,发病率有明显增加的趋势。几乎所有一开始对内分泌治疗敏感的前列腺癌最终都将发展成雄激素非依赖性前列腺癌(AIPC)。AIPC是指对内分泌治疗无反应或内分泌治疗后反而促进疾病进展,导致不可逆的临床进展恶化,直至患者死亡。有关AIPC的发病机制以及治疗策略仍缺乏统一的认识,现就此作一综述。     

早期前列腺癌的诊断与治疗

随着前列腺癌发病率在我国的逐年升高,泌尿外科医生对此疾病的早期诊断与治疗也越来越关注。尽管美国的资料显示前列腺癌的筛查可以降低前列腺癌相关的死亡率,但对是否开展此项筛查依然存在争议。诊断方面依然以直肠指检(DRE)、前列腺特异性抗原(PSA)和B超引导的经直肠前列腺穿刺活检为主。治疗方面强调对这类患者实施治愈性治疗手段如前列腺癌根治术和放疗。严密的随访可以尽早发现肿瘤复发并及时开始二线治愈性治疗。本文对早期前列腺癌诊断与治疗的现状进行了综述。     

Management of Patients with Advanced Prostate Cancer: The Report of the Advanced Prostate Cancer Consensus Conference APCCC 2017

Background

In advanced prostate cancer (APC), successful drug development as well as advances in imaging and molecular characterisation have resulted in multiple areas where there is lack of evidence or low level of evidence. The Advanced Prostate Cancer Consensus Conference (APCCC) 2017 addressed some of these topics.

Cancer-related pain and quality of life in prostate cancer patients: Assessment using the Functional Assessment of Prostate Cancer Therapy

The objective of this study was to assess disease-associated pain and quality of life (QOL) in patients with prostate cancer (PC). A total of 102 PC patients (clinical stage B, C: 20, D2: 82) patients were enrolled. QOL was assessed using the Functional Assessment of Cancer Therapy, General and Prostate (FACT-G/P). Disease-specific pain response was assessed using the visual analog scale and the face rating scale. In patients with stage D2 PC, mean age, serum prostate-specific antigen level, and performance status were 72.5 ± 7.1 years (range, 55–88), 217 ± 467 ng/mL (range, 0.1–2600), and 1.4 (0–4), respectively. The score of physical well-being and FACT-P was significantly lower in stage D2 patients, compared with those of stage B/C ( P  = 0.02, 0.0088, respectively). Performance status, extent of disease, and the visual analog scale were related with a poor QOL score ( P  = 0.0054, 0.01, <0.0001, respectively). Thirty-two patients (39%) had disease-specific pain, and 25 patients received a related treatment. Ten patients under morphine analgesics maintained better QOL in almost all domains, compared with the seven patients without any painkillers. Combined use of FACT and pain scales enhances the objective assessment of QOL and pain status in PC patients. Control of disease-associated pain is crucial to improving QOL in stage D2 PC patients.     

输精管结扎术与前列腺癌发病风险关系的Meta分析

目的:评价输精管结扎术与前列腺癌发病风险的关系。方法:以"前列腺癌"、"输精管结扎术"及其同义、近义词为关键词,在CBMDisc、CMCC、CMAC、CNKI(1978年至2009年1月6日)和PubMed(1965年至2009年1月6日)等国内外数据库上进行全面检索,按文献纳入及剔除标准筛选出符合要求的文献,提取出相关数据,以RevMan4.2进行一致性检验后采取随机效应模型对纳入研究的文献进行综合定量分析,求出合并OR值及95%CI,并分层分析结扎年限<20年和≥20年与前列腺癌发病风险的OR值及95%CI。结果:共有27篇文献纳入研究,其中队列研究7篇,病例对照研究20篇,共收集研究对象252594例,其中病例20088例,对照232506例。合并OR值(95%CI)为1.10(0.97～1.24),分层分析显示结扎年限<20年和≥20年的合并OR值(95%CI)分别为0.94(0.83～1.06)和1.05(0.90～1.23)。结论:现有研究表明输精管结扎术不会增加前列腺癌的发病风险。     

Prostate cancer in Mexican-Americans: identification of risk factors

BACKGROUND: There is a paucity of information regarding prostate cancer (PCa) risk factors among Hispanics, the fastest-growing ethnic group in the United States. METHODS: This population-based case-control study included 176 Texas men of Mexican descent with PCa and 174 age- and ethnicity-matched controls. Demographic, lifetime occupational history, family history of cancer, lifestyle (e.g., smoking, alcohol, diet, and recreational physical activity) and anthropometric information were collected by personal interviews. Chemical exposure and physical activity were determined using job-exposure matrices for each reported job. RESULTS: Logistic regression models adjusted for relevant covariates were used to evaluate their independent effects. Compared to controls, cases were three times more likely to work in jobs with high agrichemical exposure (OR = 3.44, 95% CI 1.84-6.44), and 54% less likely to work in jobs with moderate/high occupational physical activity (OR = 0.46, 95% CI 0.28-0.77). In analyses stratified by stage, cases with organ-confined PCa were three times more likely to have high agrichemical exposure (OR = 3.39, 9%CI 1.68-6.84), and 56% less likely to have moderate/high levels of occupational physical activity (OR = 0.44, 95% CI 0.26-0.76). Increased risk of being diagnosed with advanced PCa was associated with obesity at time of diagnosis (OR = 2.50, 95% CI 1.20-5.20) and high levels of agrichemical exposure (OR = 4.65, 95% CI 1.97-10.97), but not with occupational physical activity. CONCLUSIONS: This case-control study, the first conducted in a homogeneous Hispanic population, identified modifiable PCa risk factors, such as physical activity and agrichemical exposure, which may be useful in developing interventions for this understudied population.