Effect of patient age on early detection of prostate cancer with serum prostate-specific antigen and digital rectal examination.

Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Urology (Impact Factor: 2.13). 10/1993; 42(4):365-74. DOI: 10.1016/0090-4295(93)90359-I
Source: PubMed

ABSTRACT This study was designed to determine the effects of age by decade on the efficacy of digital rectal examination (DRE) and serum prostate-specific antigen (PSA) for early detection of prostate cancer in men aged fifty and over. A prospective multicenter clinical trial was conducted at six university centers. All 6,630 male volunteers underwent a serum PSA (Hybritech, Tandem) determination and DRE. Quadrant biopsies of the prostate were performed if PSA was > 4 ng/mL or DRE suspicious. A total of 1,167 biopsies were performed, and 264 cancers were detected. The cancer detection rate increased from 3 percent in men aged fifty to fifty-nine to 14 percent in men eighty years or older (p < 0.0001). PSA detected significantly more of the total cancers than DRE at all age ranges (p < 0.05). The positive predictive values (PPV) for PSA were 32 percent (50-59 years), 30 percent (60-69 years), 34 percent (70-79 years), and 38 percent (80+ years). The corresponding PPVs for DRE were 17 percent, 21 percent, 25 percent, and 38 percent. Eighteen percent of the cancers were detected solely by DRE, whereas 45 percent of cancers were detected solely by PSA. Thus, the use of both tests in combination provided the highest rate of detection in all age groups. One hundred-sixty patients underwent radical prostatectomy and pathologic staging. Cancer was organ-confined in 74 percent (25/34) of men aged fifty to fifty-nine, 76 percent (65/86) of men aged sixty to sixty-nine, and 60 percent (24/40) of men aged seventy or over (chi 2, < 70 vs. > or = 70, p < 0.05). Early detection programs yield a lower, yet still substantial, cancer detection rate in younger men, and there is a greater likelihood for detection of organ-confined disease in this age range. Younger men have the longest projected life expectancy and, therefore, the most to gain from early prostate cancer detection.

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    ABSTRACT: Evidence demonstrating the burden of prostate cancer on men in the United States is incontrovertible; less compelling is evidence of benefit from early detection efforts. Thus is framed one of the great controversies of contemporary preventive medicine: Should early detection efforts for prostate cancer be promoted as part of the periodic health examination? There is no doubt that prostate cancer is a highly prevalent and commonly lethal cancer. Approximately 179,300 men will be diagnosed with prostate cancer in 1999, and 37,000 men will die of the disease making prostate cancer the second leading cause of cancer death among U.S. men.27 Furthermore, currently available tools clearly allow its detection during a long asymptomatic phase; however, the effectiveness of these tools in detecting prostate cancers whose natural history can be favorably influenced by currently available treatment modalities has not yet been established in randomized, controlled trials.Lacking this gold standard evidence, advocates of early detection point to changes in the epidemiology of prostate cancer in the United States.42 After its approval by the U.S. Food and Drug Administration in 1986 as a technique to monitor prostate cancer and in 1994 for early detection, use of prostate-specific antigen (PSA) testing has become commonplace. The apparent impact of these efforts is manifest in the abrupt and substantial increase in the incidence of prostate cancer, which peaked in 1992 for white and 1993 for African-American men, then declined as the pool of prevalent cases was reduced. More important from the perspective of early detection advocates has been the associated reversal of the preceding 20-year history of progressive rise in prostate cancer mortality.42 Although this decline in prostate mortality may reflect other changes in risk factors or treatment, the possibility that increased early detection efforts have contributed to this decline cannot be excluded.A substantial body of evidence is relevant to any consideration of the effectiveness and wisdom of early detection efforts directed toward prostate cancer, and highlights of this evidence are considered in this article. Individual reviewers of these data, however, come to different conclusions, and this is reflected in the variety of policy recommendations issued by professional organizations. For example, although the American Cancer Society2 and 31 and American Urological Association3 both advocate offering routine PSA screening to men 50 years old or older, the U.S. Preventive Services Task Force55 and American College of Physicians12 do not. Many factors contribute to these differences, including the selection and evaluation of supporting evidence and the requirement of data from randomized, controlled trials demonstrating effectiveness versus extrapolation based on best available data.From a primary care perspective, it is also critical to distinguish public policy from decision making in the care of individuals. Public policy must be responsive to the impact of decisions on the population as a whole, whereas it is the best interests of the individual that dominate decision making in patient care, and these must reflect consideration of an individual's perceptions of risk, benefit, and their tradeoff. In the absence of definitive evidence of net benefit or harm from early detection efforts, it is reasonable for the counseling physician to provide a man the information he needs to engage in a process of informed, shared decision making. The physician's recommendation is relevant to this process, and this article assists the reader in drawing his or her own conclusion concerning the role of prostate testing or to come to the conclusion that a definitive answer is not currently available. This article also provides the counseling physician the information and methods necessary to assist interested men in making prostate testing decisions that are personally appropriate. In fact, this emphasis on shared and informed decision making narrows the otherwise suggested incompatibility of the prostate testing recommendations of various organizations. The American Cancer Society, for example, although advocating testing, carefully states that testing should be offered to men who are first informed of the potential risks and benefits in advance of individual decision making.2 Similarly, although not advocating routine testing, the American College of Physicians encourages physicians to describe the potential benefits and harms of testing, then individualize the decision to screen.12 Thus, this article does not resolve the prostate cancer detection controversy. Rather the goal here is more modest but still challenging. This article is intended to encourage and equip physicians to assist men in making well-informed prostate cancer detection decisions, which are consistent with the man's personal preferences and the best available data.
    Medical Clinics of North America 11/1999; 83(6):1423-1442. · 2.80 Impact Factor
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    ABSTRACT: The purpose of our study was to test our hypothesis that multiparametric magnetic resonance imaging (mpMRI) may have a higher prognostic accuracy than the Partin tables in predicting organ-confined (OC) prostate cancer and extracapsular extension (ECE) after radical prostatectomy (RP).
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    ABSTRACT: There remains significant controversy around the optimal criteria for recommending prostate biopsy. To examine this issue further, urologists in the Michigan Urological Surgery Improvement Collaborative (MUSIC) assessed statewide prostate biopsy practice patterns and variation in prostate cancer (PCa) detection. MUSIC is a statewide physician-led collaborative designed to improve prostate cancer care. From 3/2012 through 6/2013, 17 MUSIC practices collected standardized clinical and pathological data for 3,015 men undergoing first-time prostate biopsy. We examined pathologic biopsy outcomes according to patient characteristics and across MUSIC practices. The overall cancer detection rate was 52%, with significant variability across MUSIC practices (range: 43% to 70%, p<0.0001). 27% of all patients biopsied were > 69 years, ranging from 19% to 36% at individual practices. Men with a PSA < 4 ng/ml were 26% of the study population (range: 10% to 37%). Detection rates in patients > 69 years ranged from 42% to 86% for individual practices (p=0.0008). For patients with PSA < 4 (n=793), cancer detection rates ranged from 22% to 58% across individual practices (p=0.0065). The predicted probability of cancer detection varied significantly across MUSIC practices (p<0.0001), even after adjusting for patient age, PSA, prostate size, family history and DRE findings. While overall detection rates are higher than previously reported, cancer yield for prostate biopsy varies widely across urology practices in Michigan. These data serve as a foundation for our efforts to understand and improve patient selection for prostate biopsy.
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