There were numerous presentations at yesterday’s AUA sessions related to prostate cancer. We have identified six presentations of general significance to risk for prostate cancer in general and newly diagnosed patients.
Does Baseline PSA Level Trump Other Risk Factors in Long-Term Risk for Prostate Cancer?
Compelling data has recently been emerging about the prognostic power of a man’s baseline PSA value and risk of developing prostate cancer. The question therefore arises whether baseline PSA values have the same predictive power in men who are already at a high risk for developing prostate cancer based on their family history, race, or ethnicity. Mondo et al. have suggested that this is indeed the case. Their study examined 329 African American patients with a positive family history of prostate cancer who enrolled in a longitudinal prostate cancer screening study. These high risk men all had a baseline PSA value below the age-adjusted median and appeared to be unlikely to develop prostate cancer despite their high risk status based on traditional risk factors.
Deferred vs. Immediate Therapy
Shappley et al. reported data on deferred management of prostate cancer (”active surveillance” or “watchful waiting”)from the Physicians’ Health Study — a large prospectively maintained nationwide database. From 1982 to 2004, 2,587 cases of prostate cancer were identified. In 2003-05, the authors collected treatment information from 1,288 survivors. Deferred therapy was defined as a delay in definitive treatment for more than 1 year. Not surprisingly, patients managed with delayed treatment were older (71.1. vs 67.9 years) and had lower risk disease. Of the patients who initially started on watchful waiting, 38 percent were left untreated at the mean follow-up of 7 years. When rates of metastatic progression were compared between patients who elected deferred treatment and those who were treated immediately, no statistical differences were seen.
While this retrospective comparison involves patient groups at a very different risks of disease progression, it is reassuring to note that there was no apparent difference in outcome between the groups over an average 7-year follow-up.
External Beam RT and Risk for Secondary Malignancies
An international group of investigators (Bhojani et al.) evaluated men treated with either radical prostatectomy (n = 6,196) or external beam radiation therapy (n = 4,137) between 1983 and 2004. Hormonal therapy was not used in either group. Their objective was to examine risk for subsequent treatment for bladder, lung, or colorectal cancer. The investigators controlled for age, baseline co-morbidities, and year of treatment.
Their analysis showed that a history of external beam radiotherapy resulted in a threefold higher risk for cystectomy (p = 0.04), a 1.8-fold increase in risk for lobectomy or pneumonectomy (p = 0.02), and a 1.7- fold higher risk of colectomy (p = 0.02). Whether newer radiotherapy methods (e.g., intensity-modulated radiation therapy) confer the same risks is unknown. However, the authors note that these data “should be certainly remembered when counseling young patients with localized prostate cancer.”
Agent Orange and Risk for Prostate Cancer
Tens of thousands of US veterans are known to have been exposed to Agent Orange during the Vietnam War. Previous studies have examined the relationship of Agent Orange with incidence of prostate cancer. Some believe that studies reported to date have been too small, examined patients that were too young, or were conducted in the pre-PSA era.
Chamie et al. re-examined this issue using clinical data from 17,000 Vietnam War era veterans who received care in the Northern California VA system: 6,214 were exposed to Agent Orange, while 6,930 patients had no documented exposure. The exposed veterans were more likely to develop prostate cancer (239 vs 124 men). Moreover, exposed patients presented at a younger age (59.7 vs 62.2 years), had higher grade disease (twofold increase in Gleason score 8-10), and were more likely to present with metastases (13.4 vs 4.0 percent). If these findings are substantiated, it seems reasonable that patients with history of Agent Orange exposure should be screened earlier for prostate cancer. These results may also impact Service Connection policies of VA Medical Centers.
Guidance for Newly Diagnosed Patients with Low Risk Prostate Cancer
Kim et al. examined outcomes for 846 low risk prostate cancer patients (PSA <10, Gleason 6, clinical stage T1c) who underwent radical retropubic prostatectomy. Ten years post-surgery, PSA-free survival and prostate cancer specific survival were 94.5 and 99.8 percent, respectively. Only three patients (0.35 percent) died of prostate cancer in this group. While these results are certainly impressive, we still need to know whether similar results might have been apparent (at least in the older cohorts of these patients) if they have been maanged with active surveillance. Life on its own is not enough. There should be a continuing quality to that life, which was not explored in this study.
Does Insurance Coverage Impact Risk for Progressive Prostate Cancer?
The relationship between the patient’s health coverage and risk for prostate cancer has long been considered to be a potential issue. Using data from the CaPSURE database, Dall’Era et al. have shown that (in the USA) patients with Medicaid/Medicare coverage were more likely to present with intermediate or high risk prostate cancer than individuals with private insurance coverage. The latter were more likely to be diagnosed with low risk disease.
Clearly there are many unanswered questions here: Are these findings an indirect consequence of America’s $5 million uninsured? Do men with Medicaid/Medicare present with higher risk disease because they were uninsured prior to getting public health care coverage? Were these men, unlike their privately insured counterparts, not screened for prostate cancer prior to receiving Medicaid/Medicare coverage? More research will be important if we are to understand the results of this study in detail.
There were numerous presentations at yesterday’s AUA sessions related to prostate cancer. We have identified six presentations of general significance to risk for prostate cancer in general and newly diagnosed patients.
Does Baseline PSA Level Trump Other Risk Factors in Long-Term Risk for Prostate Cancer?
Compelling data has recently been emerging about the prognostic power of a man’s baseline PSA value and risk of developing prostate cancer. The question therefore arises whether baseline PSA values have the same predictive power in men who are already at a high risk for developing prostate cancer based on their family history, race, or ethnicity. Mondo et al. have suggested that this is indeed the case. Their study examined 329 African American patients with a positive family history of prostate cancer who enrolled in a longitudinal prostate cancer screening study. These high risk men all had a baseline PSA value below the age-adjusted median and appeared to be unlikely to develop prostate cancer despite their high risk status based on traditional risk factors.
Deferred vs. Immediate Therapy
Shappley et al. reported data on deferred management of prostate cancer (”active surveillance” or “watchful waiting”)from the Physicians’ Health Study — a large prospectively maintained nationwide database. From 1982 to 2004, 2,587 cases of prostate cancer were identified. In 2003-05, the authors collected treatment information from 1,288 survivors. Deferred therapy was defined as a delay in definitive treatment for more than 1 year. Not surprisingly, patients managed with delayed treatment were older (71.1. vs 67.9 years) and had lower risk disease. Of the patients who initially started on watchful waiting, 38 percent were left untreated at the mean follow-up of 7 years. When rates of metastatic progression were compared between patients who elected deferred treatment and those who were treated immediately, no statistical differences were seen.
While this retrospective comparison involves patient groups at a very different risks of disease progression, it is reassuring to note that there was no apparent difference in outcome between the groups over an average 7-year follow-up.
External Beam RT and Risk for Secondary Malignancies
An international group of investigators (Bhojani et al.) evaluated men treated with either radical prostatectomy (n = 6,196) or external beam radiation therapy (n = 4,137) between 1983 and 2004. Hormonal therapy was not used in either group. Their objective was to examine risk for subsequent treatment for bladder, lung, or colorectal cancer. The investigators controlled for age, baseline co-morbidities, and year of treatment.
Their analysis showed that a history of external beam radiotherapy resulted in a threefold higher risk for cystectomy (p = 0.04), a 1.8-fold increase in risk for lobectomy or pneumonectomy (p = 0.02), and a 1.7- fold higher risk of colectomy (p = 0.02). Whether newer radiotherapy methods (e.g., intensity-modulated radiation therapy) confer the same risks is unknown. However, the authors note that these data “should be certainly remembered when counseling young patients with localized prostate cancer.”
Agent Orange and Risk for Prostate Cancer
Tens of thousands of US veterans are known to have been exposed to Agent Orange during the Vietnam War. Previous studies have examined the relationship of Agent Orange with incidence of prostate cancer. Some believe that studies reported to date have been too small, examined patients that were too young, or were conducted in the pre-PSA era.
Chamie et al. re-examined this issue using clinical data from 17,000 Vietnam War era veterans who received care in the Northern California VA system: 6,214 were exposed to Agent Orange, while 6,930 patients had no documented exposure. The exposed veterans were more likely to develop prostate cancer (239 vs 124 men). Moreover, exposed patients presented at a younger age (59.7 vs 62.2 years), had higher grade disease (twofold increase in Gleason score 8-10), and were more likely to present with metastases (13.4 vs 4.0 percent). If these findings are substantiated, it seems reasonable that patients with history of Agent Orange exposure should be screened earlier for prostate cancer. These results may also impact Service Connection policies of VA Medical Centers.
Guidance for Newly Diagnosed Patients with Low Risk Prostate Cancer
Kim et al. examined outcomes for 846 low risk prostate cancer patients (PSA <10, Gleason 6, clinical stage T1c) who underwent radical retropubic prostatectomy. Ten years post-surgery, PSA-free survival and prostate cancer specific survival were 94.5 and 99.8 percent, respectively. Only three patients (0.35 percent) died of prostate cancer in this group. While these results are certainly impressive, we still need to know whether similar results might have been apparent (at least in the older cohorts of these patients) if they have been maanged with active surveillance. Life on its own is not enough. There should be a continuing quality to that life, which was not explored in this study.
Does Insurance Coverage Impact Risk for Progressive Prostate Cancer?
The relationship between the patient’s health coverage and risk for prostate cancer has long been considered to be a potential issue. Using data from the CaPSURE database, Dall’Era et al. have shown that (in the USA) patients with Medicaid/Medicare coverage were more likely to present with intermediate or high risk prostate cancer than individuals with private insurance coverage. The latter were more likely to be diagnosed with low risk disease.
Clearly there are many unanswered questions here: Are these findings an indirect consequence of America’s $5 million uninsured? Do men with Medicaid/Medicare present with higher risk disease because they were uninsured prior to getting public health care coverage? Were these men, unlike their privately insured counterparts, not screened for prostate cancer prior to receiving Medicaid/Medicare coverage? More research will be important if we are to understand the results of this study in detail.
Filed under: Diagnosis, Management, Treatment