LA CONSULTA SEMANAL

AGOSTO 2000

CONSULTA

Prostate 2000 Aug 1;44(3):255-63
Screening and early detection of prostate cancer.
Schroder FH, Alexander FE, Bangma CH, Hugosson J, Smith DS
Department of Urology, Erasmus University, Rotterdam, The Netherlands.
Publication Types:
  Review
  Review, tutorial

Arch Esp Urol 2000 May;53(4):333-41
[Clinical usefulness of free PSA/total PSA ratio in the early diagnosis of prostatic cancer].
Laguna Pes MP, Guinda Sevillano C, Zazo Romojaro A, Dominguez J, Garcia Luzon A, Borrego Hernando J, Gimeno Collado A
Servicio de Urologia, Hospital General La Mancha-Centro, Alcazar de San Juan, Ciudad Real, Espana.
OBJECTIVES: To determine the clinical utility of free/total PSA ratio and PSA density in the early diagnosis of prostate cancer (patients with serum PSA between 4 and 10 ng/ml) and to determine the differences, if any, in the free/total PSA ratio in patients with cancer and those with benign prostatic hyperplasia (BPH). METHODS: A prospective and descriptive study was conducted on 61 patients with low grade obstructive symptoms and total serum PSA between 4 and 10 ng/ml (group 1), and 42 patients who underwent prostate surgery and had an anatomopathologically confirmed diagnosis of BPH (group 2). Free and total PSA were determined, as well as prostate volume by transrectal US, in all cases. Prostate biopsy was performed in all patients with a total PSA value between 4-10 ng/ml. The sensitivity, specificity, positive and negative prognostic values of free/total PSA ratio and PSA density were analyzed. RESULTS: The mean age of the patients in group 1 was 67.7 years and 68.3 years in group 2. The mean prostate volume by US was 55.2 and 47.1, respectively (n.s.). The mean total PSA was 6.39 ng/ml for group 1 and 5.73 ng/ml for group 2 (n.s.). No significant difference was found between the mean free PSA values of both groups. However, the free/total PSA ratio and PSA density were significantly different (p < 0.000). In group 1 (total PSA 4-10 ng/ml), prostate biopsy was positive in 32.8% of the patients. In this group of patients, there were no significant differences in the parameters analyzed. Application of different cutoffs for both tests showed a higher clinical utility for the 0.24-0.30 range. CONCLUSIONS: At similar mean prostate volume and mean total PSA, significant differences were found in the free/total PSA ratio and PSA density of patients submitted to surgery for BPH and those with a total PSA value of 4-10 ng/ml. However, these results were not observed when patients with PSA of 4-10 ng/ml were analyzed for presence or absence of evidence of malignancy in the prostate
biopsy.

Urology 2000 Jun;55(6):796-9
A PSA threshold of 4.0 ng/mL for early detection of prostate cancer: the only rational approach for men 50 years old and older.
Carter HB
Publication Types:
  Editorial

J R Coll Surg Edinb 2000 Apr;45(2):127-31[Texto completo]
Screening for early prostate cancer: what is the problem?
Moffat L
Department of Urology, Grampian University Hospitals Trust, Aberdeen, U.K. uro-oncology@abdn.ac.uk
Screening has been applied to normal populations to detect early cancers. Prostate cancer is very common and can be detected at an early stage. Screening has not been introduced in the UK for this disease and the possible reasons for this are discussed. There is a strong case for evaluation of screening
programmes for this disease.

Prostate 2000 May 15;43(3):215-22
Screening and early hormonal treatment of prostate cancer are accumulating strong evidence and support.
Labrie F
Oncology and Molecular Endocrinology Research Center, Department of Medicine, CHUL Research Center, Centre Hospitalier Universitaire de Quebec and Laval University, Quebec City, Quebec, Canada. fernand.labrie@crchul.ulaval.ca
BACKGROUND: I review the data published during the last 5 years on the effects of early treatment of prostate cancer on survival. METHODS: Data from prospective and randomized studies as well as from population-based studies are presented. RESULTS: Two studies (European Organization for Research and Treatment of Cancer and Radiation Therapy Oncology Group) in stage T3 disease have shown that long-term (3 years or indefinite, respectively) androgen blockade prolongs life in patients receiving androgen blockade in addition to radiotherapy compared to radiotherapy alone. In the UK Medical Research Council study, androgen blockade at diagnosis of locally advanced or asymptomatic patients decreased cancer-specific death by 21% compared to delayed treatment. A 69% decrease in prostate cancer death was observed in the Quebec Randomized Prostate Cancer Screening Study. Population-based studies in Sweden and Denmark have shown that 62% and 63%, respectively, of patients diagnosed with localized prostate cancer will die from the disease if not treated immediately. Decreases in prostate cancer death rate of 6.3-23% have been found between 1991-1997 in the US and Canada, respectively. CONCLUSIONS: Treatment of localized disease has been shown in all the available randomized studies to cause a marked decrease in prostate cancer death. Simple use of the available screening procedures and treatments for localized prostate cancer could cause a dramatic decrease in prostate cancer death. Copyright 2000 Wiley-Liss, Inc.
Publication Types:
  Review
  Review, tutorial
Comments:
  Comment in: Prostate 2000 May 15;43(3):223-4

Urol Int 1999;63(2):102-6
Possibility of improving the acceptance rateof early detection testing for prostate cancerwith a one-step test for prostate-specific antigen in whole blood.
Berg W, Linder C, Eschholz G, Link S, Schubert J
Department of Urology, University Hospital, Friedrich Schiller University, Jena, Germany. linder@landgraf.med.uni-jena.de
In order to increase the acceptance rate of early detection testing for prostate cancer, a qualitative prostate-specific antigen (PSA) one-step test has been developed. Determining the PSA level with this test system takes 10 min. The blood samples of 190 men were tested in this qualitative assay, which uses 50 microl of EDTA whole blood and in which the results are ascertained visually. Parallel samples were tested in serum-based, quantitative assays (Abbott Imx, EIA). The findings of the two kinds of assays were compared and evaluated regarding their correspondence (<4.0 and > or = 4.0 ng/ml). For the 74 blood samples in which the quantitative assay showed PSA levels <4.0 ng/ml, the PSA one-step test showed 83.8% correct negative results (corresponds to diagnostic specificity). For the 116 samples in which the classic assay showed PSA levels > or = 4.0 ng/ml, the one-step test showed 90.5% correct positive results (sensitivity). The noted deviations appear especially around the cut-off value of 4.0 ng/ml, i.e. within the PSA concentration range of 3.0 < 4.0 and 4.0 < 5.0 ng/ml. The qualitative PSA one-step test presented here demonstrates good reproducibility. It can be conducted by the patient and is easy to use. The test offers a simple, feasible method for early detection programs for prostate cancer. Copyright Copyright 1999 S. Karger AG, Basel

Actas Urol Esp 1999 Sep;23(8):688-93
[Early diagnosis of prostate cancer in patients with prostate symptoms by DRE, PSA, TRU and DPSA].

Minguez Martinez R, Fernandez Borrell A, Gomez Sancha F, Ruiz Zarate C, Teba del Pino F, Romero Tejada JC, Arellano Ganan R, Pereira Sanz I
Servicio de Urologia, Hospital Universitario de la Princesa, Madrid.
Presentation of our experience in the early diagnosis of prostate cancer in patients with signs and symptoms of prostatism. Over a one year period (96-97), 316 patients underwent biopsy based on clearly defined criteria according to the diagnostic algorithm used in our centre: suspicious DRE and/or PSA > or = 10 ng/mL, and in patients with PSA between 4 and 10 ng/mL in the presence of suspicious TRU or when DPSA was > or = 0.15. The ratio of the 136 (43%) prostate cancer diagnosed relative to biopsy +/- was 1:1.32. It is concluded that early diagnosis in a selected population is useful and shows good diagnostic yield. The diagnostic algorithm used is more than acceptable with 43% positive biopsies and a good ratio between biopsy +/-. With a cutoff of 0.15 DPSA is a good method to improve PSA significance in patients in the difficult PSA range of 4 to 10 ng/mL.

Urology 1999 Nov;54(5):780-6
Prostate-specific antigen testing for early diagnosis of prostate cancer: formulation of guidelines.
Carter HB, Pearson JD
Department of Urology, Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, Maryland 21287-2101, USA.
Publication Types:
  Review
  Review, tutorial

Urology 1999 Sep;54(3):517-22
PSA, PSA density, PSA density of transition zone, free/total PSA ratio, and PSA velocity for early detection of prostate cancer in men with serum PSA 2.5 to 4.0 ng/mL.
Djavan B, Zlotta A, Kratzik C, Remzi M, Seitz C, Schulman CC, Marberger M
Department of Urology, University Hospital of Vienna, Austria.
OBJECTIVES: To enhance the specificity of prostate cancer (PCa) detection and reduce unnecessary biopsies in men with prostate-specific antigen (PSA) levels of 2.5 to 4.0 ng/mL, we prospectively evaluated various PSA-based diagnostic parameters. METHODS: This study included 273 consecutive men with serum PSA of 2.5 to 4.0 ng/mL referred for early PCa detection or lower urinary tract symptoms. All men underwent prostate ultrasound and sextant biopsy with two additional transition zone (TZ) biopsies. If the first biopsies were negative, repeated biopsies were performed at 6 weeks. Total PSA, PSA density (PSAD), PSA density of the transition zone (PSA-TZ), free/total PSA ratio (f/t PSA), and PSA velocity (PSAV) were determined, and the sensitivity, specificity, and predictive values of these various parameters were calculated. RESULTS: Of 273 patients, 207 had histologically confirmed benign prostatic hyperplasia (BPH) and 66 had PCa. f/t PSA and PSA-TZ were the most powerful predictors of PCa, followed by PSA, PSAD, and PSAV. Areas under the receiver operating characteristic curves for f/t PSA and PSA-TZ were 74.9% and 70.1%, respectively. With a 95% sensitivity for PCa detection, an f/t PSA cutoff of 41% and a PSA-TZ cutoff of 0.095 would result in the lowest number of unnecessary biopsies (29.3% and 17.2% specificity for f/t PSA and PSA-TZ, respectively) compared with all other PSA-related parameters evaluated. CONCLUSIONS: Compared with standard total PSA assays, f/t PSA and PSA-TZ significantly enhance the sensitivity and specificity of PCa detection in a referral patient population with a total PSA of 2.5 to 4.0 ng/mL.

Can Oncol Nurs J 1998 Nov;8(4):262-4
The early detection of prostate cancer. Prostate Cancer Alliance of Canada.
In determining whether or not to undergo early detection tests (PSA and DRE), men must weight the possibility of early diagnosis and treatment of potentially aggressive prostate cancer against the limitation of these tests and decisions they will be faced with regarding treatment choices, effectiveness and side effects. The Prostate Cancer Alliance recommends that men 50 years of age or older talk to their physicians and inform themselves about the benefits and risks of early detection testing using PSA and DRE in order to make an informed decision about whether to have the tests. Men in higher risk categories (those with a family history of the disease or with an African Canadian ancestry) should consider this recommendation starting at age 40. Extensive information is available on these matters. Men should request such information from their family physician or their urologist and consult any or all of the groups sponsoring this message.
Publication Types:
  Guideline
  Practice guideline

CMAJ 1998 Nov 3;159(9):1139-46 [Texto completo]
Prostate cancer: 5. Diagnostic tools for early detection.
Karakiewicz PI, Aprikian AG
Department of Urology, McGill University, Montreal, Que.
Publication Types:
  Review
  Review, tutorial
Comments:
  Comment in: CMAJ 1999 Jul 13;161(1):20

JAMA 1998 May 13;279(18):1440-1
Detection of early prostate cancer: serendipitous or systematic?
Pitts WR Jr
Publication Types:
  Comment
  Letter
Comments:
  Comment on: JAMA 1997 Nov 12;278(18):1516-9

Actas Urol Esp 1997 Oct;21(9):843-51
[PSAD and PSA-AD in the early diagnosis of cancer of the prostate].
Allepuz Losa C, Sanz JI, Carela J, Benejam J, Garcia-Miralles R, Rioja Sanz LA
Servicio de Urologia, Hospital Miguel Servet, Zaragoza.
Presentation and analysis of results from an early diagnosis program for prostate cancer in symptomatic patients. Output of density-PSA (PASD-d), density-PSA of the transitional area (PSAD-ad) and free PSA/total PSA ratio, applied to patients with total PSA between 4 and 10 ng/ml is analyzed.

Actas Urol Esp 1997 Oct;21(9):827-34
[Early diagnosis of cancer of the prostate. 5-year analysis].
Sanz Velez JI, Allepuz Losa C, Gil Sanz MJ, Plaza L, Castrillo J, Cuesta Presedo JM, Rioja Sanz LA
Servicio de Urologia, Hospital Miguel Servet, Zaragoza.
The authors present the results obtained using a program for early diagnosis in symptomatic patients, within a specific population area. The effectiveness of this diagnosis program for prostate cancer, which is expected to be used also for diagnosis of less advanced stages, is established with the analysis of results obtained in 1000 patients: 42.5% positive biopsies. Biopsy indication in case of suspicious rectal examination and/or PSA over 10 ng/ml is considered useful. There are more reservations towards this indication with PSA values between 4 and 10 ng/ml, where evaluation of other complementary options is
considered necessary.

Cancer 1997 Nov 1;80(9):1808-81
Review of current data impacting early detection guidelines for prostate cancer.
Proceedings of an American Cancer Society workshop. Phoenix, Arizona, March 10-11, 1997.
Publication Types:
  Congresses
  Overall

JAMA 1997 Nov 12;278(18):1516-9
Early detection of prostate cancer. Serendipity strikes again.
McNaughton Collins M, Ransohoff DF, Barry MJ
General Medicine Division, Medical Services, Massachusetts General Hospital, Boston 02114, USA.
An underappreciated characteristic of prostate cancer screening is that it may detect some prostate cancers solely by serendipity or chance. Serendipity, previously described in the detection of colonic neoplasms, could affect prostate cancer detection when a screening test result is abnormal for reasons other than the presence of prostate cancer, but prostate cancer is coincidentally detected during the subsequent evaluation of the abnormal screening result. We reviewed published articles about prostate cancer screening, searching for evidence of serendipity. We defined serendipity in digital rectal examination (DRE) screening as the discovery of a prostate cancer by the random biopsy of an area of the prostate gland other than the palpable suspicious area that prompted the biopsy. We defined serendipity in prostate-specific antigen (PSA) screening as the discovery of a prostate cancer by the random biopsy of a nonpalpable (stage T1c) prostate cancer less than 1.0 cm3 in volume, since tumors less than 1.0 cm3 are generally too small to cause elevated PSA levels. We found that serendipity may be responsible for the detection of more than one quarter of apparently DRE-detected prostate cancers and up to one quarter of apparently PSA-detected cancers. Additionally, serendipity played a larger role in the detection of smaller tumors that are common but of uncertain clinical significance. We conclude that serendipity-detected prostate cancers contribute to an overestimation of the true information value of DRE and PSA screening. Whether serendipity is advantageous in prostate cancer screening depends on the as yet uncertain outcomes for men with smaller prostate cancers. However, given our estimates of the potential magnitude of the impact of serendipity, the currently popular DRE- and PSA-based screening strategy may not be optimal. If smaller prostate cancers are important, then we are not finding enough; if they are unimportant, then we are finding too many that we may feel compelled to treat aggressively.
Comments:
  Comment in: JAMA 1998 May 13;279(18):1439; discussion 1441
  Comment in: JAMA 1998 May 13;279(18):1439-40; discussion 1441
  Comment in: JAMA 1998 May 13;279(18):1440; discussion 1441
  Comment in: JAMA 1998 May 13;279(18):1440-1

Cancer 1997 Nov 1;80(9):1805-7
American Cancer Society guidelines for the early detection of prostate cancer: update, June 10, 1997.
von Eschenbach A, Ho R, Murphy GP, Cunningham M, Lins N
American Cancer Society Prostate Task Force, USA.
Publication Types:
  Guideline
  Practice guideline

Am Fam Physician 1997 Oct 15;56(6):1674-5
ACP issues guidelines on the early detection of prostate cancer and screening for prostate cancer.
Rose VL
Comments:
  Comment in: Am Fam Physician 1997 Oct 15;56(6):1563-4, 1567-8

Ann Intern Med 1997 Mar 15;126(6):468-79 [Texto completo]
Early detection of prostate cancer. Part II: Estimating the risks, benefits, and costs. American College of Physicians.
Coley CM, Barry MJ, Fleming C, Fahs MC, Mulley AG
Massachusetts General Hospital, Boston, USA.
PURPOSE: To evaluate the potential benefits, harms, and economic consequences of digital rectal examination and measurement of prostate-specific antigen (PSA) for the early detection of prostate cancer. DATA SOURCES: Relevant studies were identified from a MEDLINE search (1966 to 1995), reviews, bibliographies of retrieved articles, author files, and abstracts. STUDY SELECTION: Probabilities for individual clinical outcomes were derived from various sources, including the largest screening study of community volunteers to data, analyses of Medicare claims, and recently published meta-analyses of the outcomes of alternative treatment strategies. Cost estimates were based on the 1992 Medicare fee schedule. DATA EXTRACTION: A cost-effectiveness model for one-time digital rectal examination and PSA measurement was constructed to examine the possible outcomes. RESULTS: If a favorable set of assumptions is used, one-time digital rectal examination and PSA measurement may increase average life expectancy by approximately 2 weeks at a reasonable marginal cost for men who are between 50 and 69 years of age. Considerable iatrogenic illness would occur. If less  favorable assumptions are used, the estimated net benefit would decrease and cost-effectiveness ratios would dramatically increase. Even if favorable assumptions are used, the model suggests that screening adds only a few days to the average life expectancy of men who are older than 69 years of age. If the assumptions are less favorable, older men are harmed. CONCLUSIONS: The model suggests that screening may be reasonable in younger men if optimistic assumptions consistent with existing observational data are made. The lack of direct evidence showing a net benefit of screening for prostate cancer seems to mandate more clinician-patient discussion for this procedure than for many other routine tests.
Publication Types:
  Guideline
  Practice guideline
Comments:
  Comment in: Ann Intern Med 1997 Mar 15;126(6):465-7
  Comment in: Ann Intern Med 1997 Oct 15;127(8 Pt 1):656; discussion 657
  Comment in: Ann Intern Med 1997 Oct 15;127(8 Pt 1):656-7

Ann Intern Med 1997 Mar 1;126(5):394-406 [Texto completo]
Early detection of prostate cancer. Part I: Prior probability and effectiveness of tests. The American College of Physicians.
Coley CM, Barry MJ, Fleming C, Mulley AG
Massachusetis General Hospital, Boston, USA.
PURPOSE: To estimate the prevalence of clinically important prostate cancer and to evaluate the effectiveness of digital rectal examination and measurement of prostate-specific antigen (PSA) in early detection of prostate cancer. DATA SOURCES: Relevant studies were identified from a structured MEDLINE search (1966 to 1995), reviews, bibliographies of retrieved articles, author files, and abstracts. STUDY SELECTION: Articles selected for analysis of test effectiveness were prospective cohort studies of early detection that did not have obvious selection bias. DATA EXTRACTION: Likelihood ratios for digital rectal examination and PSA measurement were estimated from studies that specified the age distribution of participants. DATA SYNTHESIS: In patients who have abnormalities on digital rectal examination, the risk for a large intracapsular tumor is increased twofold but the risk for extracapsular disease is increased threefold to ninefold. An elevation in PSA level greater than 4 ng/mL increases the odds of intracapsular tumors by as much as threefold and the odds of extracapsular tumors by threefold to fivefold. For studies in which biopsies were done if results of either test were abnormal, 18% to 26% of screened patients had suspicious results, cancer detection rates were approximately 4%, and the positive predictive value of the tests combined was 15% to 21%. Men who have lower urinary tract symptoms that are consistent with benign prostatic hyperplasia are not more likely to harbor prostate cancer; the specificity of PSA measurement is considerably lower among these men. CONCLUSIONS: Larger-volume tumors of the prostate are common among older men. Available tests for the early detection of cancer have limited specificity, which necessitates a relatively high biopsy rate. The positive predictive value of combined digital rectal examination and PSA measurement has been defined, but the negative predictive value is less clear. Measurement of PSA is the most sensitive noninvasive test for prostate cancer. However, digital rectal examination detects cancer that would otherwise be missed by PSA measurement.
Publication Types:
  Guideline
  Practice guideline
  Review
  Review, academic