Age-Adjusted Reference Values for Prostate Specific Antigen - A Systematic Review and Meta-Analysis.

OBJECTIVES: To systematically evaluates the evidence on ethnic differences in age-adjusted reference values of PSA. MATERIALS AND METHODS: In concordance with the Preferred Reporting Items for Systematic Review and Meta-analysis statement, a review of English articles using Medline, Embase and Cochrane databases, from inception to December 2019 was conducted. Studies that reported the PSA upper reference value as 95th percentile of the cohort distribution, in healthy men aged 40 to 79, were included. Methodological quality was assessed with a modified version of the Agency for Healthcare Research and Quality checklist for cross-sectional studies. RESULTS: Forty-three studies examining 325,514 participants were included in the analysis. These were published between 1993 and 2018. Majority were prospective observational studies and reported the reference values in ten-year age intervals. Only five reports directly compared ethnic differences in PSA values. Due to missing data, six studies were not considered in the quantitative synthesis. For the remainder (37/43), heterogeneity in PSA reference values was considerable (Higgin's index = 99.2%), with age and ethnicity being the sole identified significant contributors. Accordingly, the pooled upper limits for PSA reference values were 2.1, 3.2, 4.9 and 6.5 ng/ml for men in their 40 s, 50 s, 60 s, and 70 s, respectively. CONCLUSION: Moderate quality evidence suggest that upper PSA reference limits increased with age and significant ethnic differences were present.

Ethnic and regional differences in the temporal trends of prostate cancer incidence and mortality in New Zealand.

BACKGROUND: Prostate cancer (Pca) is the most frequently diagnosed cancer in New Zealand (NZ) men and the third leading cause of cancer deaths. Temporal changes in Pca incidence and mortality have not been reported despite changes in the Pca landscape. This study aims to analyse the temporal trends in Pca with focus on ethnic and regional variations. METHODS: The study cohort was identified from the NZ Cancer Registry and the mortality collection databases. Men who were diagnosed with Pca between 2000 and 2018 were included in the incidence analysis. Men who died from Pca between 2000 and 2015 were included in the mortality analysis. Other data collected were ethnicity and geographical information. Pca incidence and mortality were calculated as age-standardized rates using the 2001 World Health Organization population. RESULTS: A total of 58 966 men were diagnosed (incidence: 105.2 per 100 000) and 14 749 men died (mortality: 49.3 per 100 000) from Pca. When compared to European men, Maori and Asian men had significantly lower Pca incidence. Mortality rates demonstrated a steady decline, which was more prominent until 2010. Maori and Pacific men had higher mortality rates when compared to European men. In most recent years, the difference in mortality is decreasing for Maori but increasing for Pacific men. There were no regional differences in mortality. CONCLUSION: Pca incidence in NZ has fluctuated over the last 20 years, while mortality rates have shown to steadily decline. Pca mortality was shown to disproportionately affect Maori and Pacific men.

The impact of the extent and location of positive surgical margins on the risk of biochemical recurrence following radical prostatectomy in men with Gleason 7 prostate cancers.

BACKGROUND: Positive surgical margins (PSM) after radical prostatectomy (RP) have been associated with increased risk of biochemical recurrence (BCR). This is heavily influenced by other clinicopathological factors. This study aims to assess the impact of the extent and location of PSM on BCR following RP for Gleason 7 carcinoma of the prostate (CaP). MATERIALS AND METHODS: All men treated with RP between 2008 and 2017 in our region for localized or locally advanced Gleason 7 CaP, were included. Clinical (age, year, preoperative prostate specific antigen) and pathological (prostate weight, positive or negative surgical margins, International Society of Urological Pathology [ISUP] grade, T stage) data were collected. PSM were subcategorised according to Extent into favourable (unifocal and <3 mm in length) or unfavourable (multifocal or ≥3 mm in length), and Location into apical only or others. The outcome was the risk of BCR which was calculated with univariable and multivariable regression models and reported as hazard ratio (HR) with 95% confidence interval (CI). RESULTS: The cohort constituted of 1433 men. Majority had ISUP 2 (71.2%) or localized (62%) disease. Men with PSM (n = 506) were at greater risk of BCR when compared to those with negative margins (adjusted HR = 1.52, [CI: 1.14-2.04], p = .005). Similar observation was demonstrated for both PSM location subgroups. As for the PSM extent category, only men with unfavourable PSM demonstrated an increase in BCR risk over negative margin (adjusted HR = 1.67, [CI: 1.23-2.28], p = .001). CONCLUSIONS: Within this study settings, PSM were generally associated with increased BCR risk. This, however, was not demonstrated in favourable PSM extent cases. Observation rather than active treatment in these men should be considered.

Prostate cancer outcomes disparities: Population survival analysis in an ethnically diverse nation.

BACKGROUND: Prostate cancer represents a significant health burden on New Zealand men. There are increasing concerns regarding inequities in prostate cancer morbidity and mortality among the different ethnic groups in New Zealand. This study aims to assess ethnic differences in survival outcomes among men newly diagnosed with prostate cancer. MATERIALS AND METHODS: The analyzed cohort included 42,563 men, 40 years or older, diagnosed with prostate cancer from January 1st, 2000 to January 1st, 2016. Overall and cancer-specific survivals were estimated for the main ethnic groups in New Zealand namely: Maori (indigenous), Pacific, Asian, and European. Hazard ratio (HR) of death from prostate cancer was calculated with Fine-Gray competing risk regression, while adjusting for age, socioeconomic deprivation, year of cancer diagnosis, residential status, presence of urology service, and cancer grade at diagnosis. RESULTS: Among all ethnic groups, Maori participants consistently had worst survival outcomes. At 15-year follow-up, the overall cumulative survival probabilities were 39.8%, 43.6%, 63.3%, and 46.5%, for Maori, Pacific, Asian and European men, respectively. In the same order, cancer-specific survivals were 62.7%, 64.3%, 79.8% and 72.0%. Maori men had 43% higher risk of dying from prostate cancer when compared to Europeans. This persisted following adjustments in the multivariable model (adjusted HR = 1.44, [95% CI: 1.29-1.61], P< 0.001). Conversely, differences in sociodemographic and cancer characteristics between Pacific and European men could explain the higher mortality risk in the former group (adjusted HR = 1.00, [95% CI: 0.84-1.19], P= 0.990). CONCLUSIONS: Significant ethnic disparities in prostate cancer survival outcomes are currently present in New Zealand. Several explanations have been proposed to account for this observation including differences in comorbidities, healthcare access and cancer grade at diagnosis.

Age-adjusted reference values for prostate-specific antigen in a multi-ethnic population.

OBJECTIVE: To establish age-adjusted reference values for prostate-specific antigen in an ethnically diverse population. METHODS: Between 2009 and 2017, data were collected from all men aged 40-79 years, who had a prostate-specific antigen test in the northern region of New Zealand, where the prostate-specific antigen testing service is provided by a single community laboratory and using the same assay analyzer. Men known to have prostate cancer, who developed prostate cancer during the study period, who were treated with finasteride, or who had prostate-specific antigen levels above 20 ng/mL were excluded. Age-adjusted prostate-specific antigen reference values were calculated for each of the main ethnic groups in the country including: Maori (indigenous), Pacific, Asian and European. For every 5-year age interval, the 95th percentile of the log prostate-specific antigen distribution was used to define the upper limit of normal. RESULTS: The study cohort included 215 132 apparently healthy men, with a median age and prostate-specific antigen concentration of 59 years and 0.9 ng/mL, respectively. Prostate-specific antigen levels for the entire cohort increased with age (Pearson correlation = 0.362, P < 0.001). This relationship was most prominent in Pacific men. Similarly, the upper reference limit for the entire cohort increased with age, from 1.60 ng/mL for men aged 40-44 years to 7.61 ng/mL for those aged 75-79 years. Significant ethnic differences were present within each interval, which was most apparent in the older age groups. CONCLUSION: Ethnic differences in age-adjusted prostate-specific antigen reference values are present in New Zealand. These need to be considered when prostate-specific antigen results are being interpreted in clinical practice.

Ethnic and socio-economic disparities in prostate cancer screening: lessons from New Zealand.

OBJECTIVES: To investigate the presence of ethnic and socio-economic disparities in prostate cancer (PCa) screening and identify its impact on cancer outcomes. MATERIALS AND METHODS: From January 2008 to December 2017, all men in the Northern region of New Zealand who had a prostate-specific antigen (PSA) test performed in the community were identified from the electronic laboratory reports database. Asymptomatic men, with no known diagnosis of PCa, were included. Variables collected were age, ethnicity, social deprivation, medical therapy, PSA test information and cancer data. Disparities were investigated by comparing the frequency of PSA testing, proportions of men screened, and rates of cancer detection, between Maori (indigenous) and non-Maori ethnic groups. RESULTS: The study cohort included 248 491 men, who each received approximately 3.45 PSA tests over the 10-year study period. Maori men were less likely to be tested compared to non-Maori men (25.4% vs 46.1% of the total aged-matched region population; P < 0.001). Moreover, they received less frequent PSA testing irrespective of their deprivation status (mean difference of 0.97 PSA tests per person; P < 0.001). The higher testing frequency in non-Maori men was associated with increased PCa diagnosis rates. Nevertheless, cancers detected in Maori men were 73% more likely to be of high grade (Gleason 8 or above), compared to those in non-Maori men. CONCLUSION: There were significant ethnic disparities in PCa screening rates in the Northern region of New Zealand. Maori men, regardless of other demographic factors, were disproportionately affected. The difference in the rates of screening by ethnicity had influenced the incidence and clinical significance of the diagnosed cancers.

Prostate cancer screening in New Zealand: lessons from the past to shape the future in the light of changing evidence.

Prostate cancer represents a significant health burden worldwide. The cancer incidence had substantially increased since the introduction of prostate specific antigen (PSA) in cancer screening. This had led to considerable debates among health professionals and epidemiologists, since PSA as a screening tool seemed to be far from perfect. In New Zealand, the controversy was quite prominent in the last three decades, with some advocating the benefits of screening, while others concerned regarding the risk of harms. With the absence of an organised screening programme and the appropriate monitoring and quality assurance procedures, the effects of the PSA testing debate had undoubtedly caused a variability in the opportunistic prostate cancer screening practices in the community. This, in addition to the recent rapid advancements in prostate cancer imaging, and updated results from randomised trials, have made it mandatory to question the validity of continuing with the current approach to prostate cancer screening. However, high-quality local data on these aspects had been lacking, which represents an ongoing challenge to developing robust and sound health policies.

Opportunistic prostate cancer screening: A population-based analysis.

BACKGROUND: Prostate specific antigen (PSA) utilization in population-based prostate cancer (CaP) screening, has been a controversial area for decades. Current recommendation in our region is for an opportunistic approach to screening, with estimated low prevalence of such practice in the community. However, our clinical observations suggested that the extent is beyond what might be expected from an opportunistic screening practice. This study aims to estimate the current prevalence and the extent of opportunistic CaP screening, and investigate the contemporary patterns of PSA testing in a large population. METHODS: From 2008 to 2017, all men in the Northern cancer network of New Zealand, who had a screening PSA test performed in a community laboratory were identified. The study variables were accessed from multiple prospectively maintained databases. These included: Age, Ethnicity, Region, Social deprivation, Medical therapy, CaP history, Gleason score, and PSA test information (results and date). Population estimations were obtained from customized an updated national census data. RESULTS: The study cohort constituted 311,725 men, with 1,208,214 PSA tests performed, in the ten-year period. The mean age at first test was 55.2 years and each man received approximately 4 PSA tests. The prevalence of opportunistic CaP PSA screening in men aged 40 to 79 years, was 87% of the region population. In the 50 to 69-year age group, 65% of men in the region had been receiving regular 2-yearly, screening PSA tests. Men who had 3 or more PSA tests, were more likely to be diagnosed with CaP (Odds ratio [OR] 1.85, P < 0.001). CONCLUSIONS: PSA based CaP screening, is a highly prevalent practice in the NZ community. This raises concerns regarding the quality of the individual counseling process and the adequacy of resources allocated to accommodate for such practice.

Overview of the 2015 American Thyroid Association guidelines for managing thyroid nodules and differentiated thyroid cancer.

The last few years have witnessed numerous publications addressing the management of thyroid nodules and differentiated thyroid cancers. The purpose of this review is to provide a simplified summary of the newly released guidelines by the American Thyroid Association. A systematic approach has been recommended to evaluate a thyroid nodule through clinical assessment, measurement of serum Thyroid Stimulating Hormone, neck ultrasonography and Fine Needle Aspiration where appropriate. This is followed by cytology analysis using the Bethesda scoring system to detect malignancy. Once diagnosed, thyroid cancers need to be staged and risk stratification needs to be applied to develop further treatment plans. Lastly, several recommendations have been presented to assure proper follow-up and support for thyroid cancer patients regardless of the treatment received.