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AUA 2019

AUA 2019: Journal of Urology: Top Papers: Prostate Cancer

Chicago, IL (UroToday.com) Dr. Klotz gave an excellent talk on the best prostate cancer papers that were published in the Journal of Urology in the last year. In the first paper discussed by Randal S et al., the authors performed a meta-analysis assessing the effect of vasectomy reversal on prostate cancer (PC) risk1. The authors compared the risk of PC in 9,754 men with vasectomy reversal, to 684,660 men who underwent vasectomy without a reversal in 5 regions in Australia, UK, and Canada. The authors concluded that there is no evidence of a link between vasectomy and PC.

The next paper mentioned by Dr. Klotz assessed the Mediterranean dietary pattern and its association with risk of aggressive PC, by Castello A, et al.2. This was a multicenter population-based study in Spain. Detailed data on 754 PC cases and 1,277 controls were collected. Several diets were analyzed and compared, including Western, prudent (vegetables, fruits, with low-fat dairy products, and whole grains), and Mediterranean (rich in fruits and vegetables, fish, legumes and olive oil). The study demonstrated that high adherence to a Mediterranean diet was associated with a lower risk of Gleason grade group (GGG) 2 with a relative risk of 0.66 (95% CI 0.46-0.96). No similar association was seen with the prudent diet or the western diet.

Next, a paper discussing the use of digital rectal examination (DRE) as an adjunct to PSA in the detection of clinically significant PC, by Halpern JA, et al.3, was mentioned.  A total of 35,350 patients who had DRE in the screening arm of the PLCO trial were reviewed.  A total of 1,713 clinically significant PCs were found. Suspicious DRE was associated with a higher risk of clinically significant PC at ten years. The increased risk was clinically relevant, especially for men with a PSA >=3 ng/ml. The authors concluded that DRE is useful as a reflex test, when the PSA is above three ng/ml, to improve specificity. The authors mentioned it should not be used as a primary screening modality to improve sensitivity.

The following discussed a paper by Kapoor DA, et al.  examined the history of the US preventative services task force (USPSTF) – its expanding authority and need to reform4. The authors discussed that the inclusiveness and transparency on issues with wide-ranging impact should not be left to the discretion of the task force, because it does not include expert members. 

A study assessing the cost-effectiveness of a urinary biomarker panel in PC risk assessment, by Govers TM, et al. was discussed next5. The authors analyzed the various biomarkers and concluded that the routine application of the SelectMDx biomarker to guide prostate biopsy decision making would improve health outcome. It would also lower the costs associated with a PC risk assessment in a population of American men at risk for PC.

Next, a study by Perlis N, et al. assessing which patients may not require repeat prostate biopsy based on PCA3 test score and mpMRI imaging6. A total of 470 patients who had a mpMRI, PCA3 test, and systematic and targeted biopsies were analyzed. The study demonstrated that in patients with a dual negative test (negative mpMRI and negative PCA3 test score) clinically significant PC was never found on biopsy.

Dr. Klotz then mentioned a paper by Mortezavi A. et al. looking at the diagnostic accuracy of mpMRI and fusion biopsy evaluated by transperineal template saturation prostate biopsy7. The authors stated that 20% of clinically significant PC would have been missed if fusion biopsy only had been performed without a systematic biopsy. The sensitivity of mpMRI for clinically significant PC was 85%, and the sensitivity of the fusion targeted biopsy was 57%.

Next, a study evaluating an aggressive biopsy strategy in men younger than 50, by Goldberg H, et al. was mentioned8.  A total of 199 patients younger than 50 who had a prostate biopsy were analyzed. Overall, 19% were diagnosed with PC, 4% had GGG>=2, and all men with a GGG>=2 had a PSA above 1.5 ng/ml. The authors concluded that the results justify a need to adopt an aggressive prostate biopsy strategy in men younger than 50 years with a PSA of 1.5 ng/ml or above.

The following mentioned study was on the impact of 5 alpha reductase inhibitors (5ARI) on disease reclassification among men on active surveillance for localized PC with favorable features, by Dai C, et al.9. A total of 635 men on active surveillance were analyzed, with no difference shown in grade re-classification between those on 5-ARI and those not on the medication.

The last paper discussed was by Ludwig WW, et al. assessing whether PSA testing could be stopped 20 years after radical prostatectomy10. A total of 732 men with undetectable PSA at 20 years following surgery were analyzed. Biochemical recurrence developed in 17 patients (2.3%), and metastatic disease developed in 1 patient. None of the patients had died of PC, and so the authors concluded that PSA testing could be safely stopped 20 years following surgery.

Presented by: Laurence Klotz, MD, University of Toronto

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois

References:
  1. Randall S, Boyd J, Fuller E, et al. The Effect of Vasectomy Reversal on Prostate Cancer Risk: International Meta-Analysis of 684,660 Vasectomized Men. J Urol. 2018 Jul;200(1):121-125. doi: 10.1016/j.juro.2018.03.005. Epub 2018 Mar 7.
  2. Castelló A, Boldo E, Amiano P, et al. Mediterranean Dietary Pattern is Associated with Low Risk of Aggressive Prostate Cancer: MCC-Spain Study. J Urol. 2018 Feb;199(2):430-437. doi: 10.1016/j.juro.2017.08.087. Epub 2017 Aug 23.
  3. Halpern JA, Oromendia C, Shoag JE, et al. Use of Digital Rectal Examination as an Adjunct to Prostate Specific Antigen in the Detection of Clinically Significant Prostate Cancer. J Urol. 2018 Apr;199(4):947-953. doi: 10.1016/j.juro.2017.10.021. Epub 2017 Oct 20.
  4. Kapoor DA. A History of the United States Preventive Services Task Force: Its Expanding Authority and Need for Reform. J Urol. 2018 Jan;199(1):37-39. doi: 10.1016/j.juro.2017.08.078. Epub 2017 Aug 19.
  5. Govers TM, Caba L, Resnick MJ Cost-Effectiveness of Urinary Biomarker Panel in Prostate Cancer Risk Assessment. J Urol. 2018 Dec;200(6):1221-1226. doi: 10.1016/j.juro.2018.07.034. Epub 2018 Aug 29.
  6. Perlis N, Al-Kasab T, Ahmad A, et al. Defining a Cohort that May Not Require Repeat Prostate Biopsy Based on PCA3 Score and Magnetic Resonance Imaging: The Dual Negative Effect. J Urol. 2018 May;199(5):1182-1187. doi:10.1016/j.juro.2017.11.074. Epub 2017 Nov 23.
  7. Mortezavi A, Märzendorfer O, Donati OF, et al. Diagnostic Accuracy of Multiparametric Magnetic Resonance Imaging and Fusion Guided Targeted Biopsy Evaluated by Transperineal Template Saturation Prostate Biopsy for the Detection and Characterization of Prostate Cancer. J Urol. 2018 Aug;200(2):309-318. doi: 10.1016/j.juro.2018.02.067. Epub 2018 Feb 21.
  8. Goldberg H, Klaassen Z, Chandrasekar T, et al. Evaluation of an Aggressive Prostate Biopsy Strategy in Men Younger than 50 Years. J Urol. 2018 Nov;200(5):1056-1061. doi: 10.1016/j.juro.2018.05.017. Epub 2018 Jul 27.
  9. Dai C, Ganesan V, Zabell J, et al. Impact of 5α-Reductase Inhibitors on Disease Reclassification among Men on Active Surveillance for Localized Prostate Cancer with Favorable Features. J Urol. 2018 Feb;199(2):445-452. doi: 10.1016/j.juro.2017.08.006. Epub 2017 Aug 5.
  10. Ludwig WW, Feng Z, Trock BJ, et. Prostate Specific Antigen Testing after Radical Prostatectomy-Can We Stop at 20 Years? J Urol. 2018 Jan;199(1):114-119. doi: 10.1016/j.juro.2017.08.041. Epub 2017 Aug 14.