Dr. Catalona and his faculty of other noted urologists led a session at the 2015 American Urological Association (AUA) annual meeting in May. The Prostate Cancer Update 2015 course reviewed a year’s worth of published prostate cancer research, focusing on articles that have immediate or possible near-term relevance to a practicing urologist.
The course instructors were William J. Catalona, M.D. (Northwestern University), Douglas M. Dahl, M.D. (Harvard University MGH), Stanley L. Liauw, M.D. (University of Chicago), Stacy Loeb, M.D. MSc (New York University), Robert B. Nadler, M.D. (Northwestern University), and Russell Szmulewitz, M.D. (University of Chicago).
Highlights from the Prostate Cancer Update Course
Epidemiology and Prevention
Prostate cancer mortality in areas with high and low prostate cancer incidence
Researchers compared Swedish men aged 50-74 years who lived in areas with an early increase of prostate cancer incidence (reflecting an increase in PSA testing) or counties with a late increase in prostate cancer incidence. Areas with more diagnosed cases of prostate cancer had lower rates of prostate cancer mortality. This suggests that PSA testing is associated with lower prostate cancer mortality.
J Natl Cancer Inst. 2014 Mar;106(3):dju007.
Selenium supplementation and prostate cancer mortality
The study followed 4,459 men diagnosed with nonmetastatic prostate cancer and examined whether selenium supplement use after diagnosis was associated with disease recurrence and prostate cancer mortality. Prostate cancer mortality rates were 87% higher among men who consumed 140 µg/day or more of selenium. The authors cautioned against men with prostate cancer using such supplements.
J Natl Cancer Inst. 2014 Dec 12;107(1):360.
Prostate cancer incidence in men receiving testosterone therapy
Researchers assessed if the incidence of prostate cancer was increased in 1,023 hypogonadal men receiving long-term testosterone therapy. Eleven men were diagnosed with prostate cancer over the study period, a much lower incidence than expected based on previous studies. In this cohort, testosterone supplementation appeared to be safe and did not increase the risk of prostate cancer.
J Urol. 2015 Jan;193(1):80-6.
Screening and Biopsy
Results from the European Randomised Study of Screening for Prostate Cancer
The European Randomised study of Screening for Prostate Cancer (ERSPC) assesses PSA testing in eight European countries. The latest results from this study after 13 years of follow-up confirmed a substantial reduction in prostate cancer mortality attributable to PSA testing.
Eligible men ages 50-74 years were randomly assigned to screening (every 2 or 4 years) or no screening (control) groups. The updated results found a 57% increase in prostate cancer in the screening group compared to the control group. There was also a 21% reduction in prostate cancer mortality in the screening group. To prevent one prostate cancer death, 781 men needed to be invited to for screening and 27 diagnosed with the disease.
Lancet. 2014 Dec 6;384(9959):2027-35.
Opportunistic testing versus organized PSA screening in the Göteborg trial
The Göteborg screening study included 20,000 men randomly assigned to one of two groups: invited for PSA testing every 2 years, or not invited for PSA testing. Prostate biopsy was recommended for men with PSA ≥2.5 ng/ml.
After 18 years of follow-up, the organized screening group had a 42% reduction in prostate cancer death. The authors concluded that organized screening reduces prostate cancer mortality, but it is associated with overdiagnosis. Opportunistic (random) PSA testing had little - if any - effect on prostate cancer mortality and resulted in more overdiagnosis.
Eur Urol. 2015 Sep;68(3):354-60.
MR/ultrasound fusion-guided biopsy vs. standard biopsy
A prospective study compared standard biopsy and MRI-targeted biopsy approaches for the detection of prostate cancer. The study included 1,003 men undergoing both types of biopsies concurrently. There was exact agreement in 69% of the cases. MRItargeted biopsy detected 30% more high-risk cancers and 17% fewer lowrisk cancers than standard biopsy.
JAMA. 2015 Jan 27;313(4):390-7
Markers & Imaging
PHI vs. PCA3 score to predict prostate cancer
The aim of this study was to compare the accuracy of PHI and PCA-3 scores to predict prostate cancer in 138 men undergoing initial biopsies. PCA3 outperformed the PHI test for predicting overall prostate cancer. However, PHI significantly outperformed PCA3 for predicting clinically-significant prostate cancer. The findings “strongly indicated that PHI should be used for populationbased screening to avoid over-diagnosis of indolent tumors that are unlikely to cause death,” wrote the authors.
Prostate. 2015 Jan;75(1):103-11.
Genomic Prostate Score predicts recurrence
Predicting outcomes in men with newly diagnosed prostate cancer can be challenging. This study demonstrated that a new molecular test, the Genomic Prostate Score, can predict a cancer’s aggressiveness and might help men make decisions regarding the need for immediate treatment.
A racially diverse cohort of men was used to evaluate the 17-gene Genomic Prostate Score with recurrence after radical prostatectomy and adverse pathology at surgery. A 20- unit increase in the Genomic Prostate Score was associated with a 3.3-times increased risk of adverse pathology at radical prostatectomy and a 2.7-times increased risk of biochemical recurrence. A 20-unit increase was also associated with metastatic disease.
Eur Urol. 2015 Jul;68(1):123-31.
Increasing use of observation
A retrospective cohort study found increasing use of observation for lowrisk cancer between 2004-2009, even in men young and healthy enough for treatment. The authors wrote this suggests growing acceptance of active surveillance in this group of patients. Researchers examined active surveillance rates in 66,499 men diagnosed with localized prostate cancer. There was a marked increased in observation from 18% in 2004 to 29% in 2009 in men with low-risk disease.
J Urol. 2015 Mar;193(3):801-6.
Active surveillance for men diagnosed with prostate cancer by PSA testing
The study assessed upgrading and upstaging in 74 men who qualified for active surveillance but were treated with radical prostatectomy. Of the 281 patients assessed in the study, 67% qualified for active surveillance. Using the initial biopsy, 33% of men who met the strict criteria for active surveillance and 25% who met the liberal criteria were upgraded and/or upstaged, versus 38% who did not quality for active surveillance. Less restrictive criteria for surveillance may be appropriate based on similar rates of upgrading/upstaging at radical prostatectomy.
J Urol. 2015 Sep;194(3):680-4
Radical prostatectomy or watchful waiting in early prostate cancer
The Scandinavian Prostate Cancer Group-4 study examined 695 men with localized prostate cancer who were randomly assigned to watchful waiting or radical prostatectomy groups. At 18 years follow-up, the radical prostatectomy group had a 44% lower prostate cancer-specific mortality and a 43% lower risk of metastases. See the Summer/Fall 2014 QUEST for indepth coverage of this study.
N Engl J Med. 2014 Mar 6;370(10):932-42.
Comparing robotic-assisted and open radical prostatectomy
The study compared effectiveness and complication rates in in 5,915 patients who underwent either open radical prostatectomy or roboticassisted radical prostatectomy. The two groups had similar odds of overall complications, hospital readmission rates and needs for additional treatments. However, the roboticassisted radical prostatectomy patients had greater costs.
J Clin Oncol. 2014 May 10;32(14):1419-26.
Radiation therapy with ADT vs. ADT alone for high-risk disease
After 8 years of follow-up, a clinical trial found that adding radiation therapy to androgen deprivation therapy (ADT) improved outcomes for men with locally advanced prostate cancer. The study included 1,205 patients assigned to ADT alone or ADT with radiation therapy. Adding radiation therapy improved overall survival and reduced prostate cancer death.
J Clin Oncol. 2015 Jul 1;33(19):2143-50.
Using genomic data to determine timing of radiation therapy after radical prostatectomy
Genomic data may improve decision making for men at high risk of relapse after radical prostatectomy. The study included 188 men who had a 22- gene analysis derived from their radical prostatectomy specimen. All the men had adjuvant or salvage radiation therapy.
The genomic classifier was effective in predicting the development of clinical metastatic disease beyond routine clinical and pathologic features. Patients with low genomic classifier scores were best treated with salvage radiation therapy, whereas patients with high genomic classifier scores benefited from adjuvant therapy. Further validation of these results is needed.
J Clin Oncol. 2015 Mar 10;33(8):944-51.