Prostate cancer screening in the Prostate, Lung, Colorectal and Ovarian cancer screening trial: update on findings from the initial four rounds of screening in a randomized trial.

OBJECTIVE: To describe the results of the first four rounds (T0-T3) of prostate cancer screening in the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial (designed to determine the value of screening in the four cancers), that for prostate cancer is evaluating whether annual screening with prostate-specific antigen (PSA) and a digital rectal examination (DRE) reduces prostate cancer-specific mortality. SUBJECTS AND METHODS: In all, 38 349 men aged 55-74 years were randomized to undergo annual screening with PSA (abnormal >4.0 ng/mL) and a DRE. The follow-up of abnormal screening results was at the discretion of subjects' physicians. PLCO staff obtained records related to diagnostic follow-up of positive screen results. RESULTS: Compliance with screening decreased slightly from 89% at baseline to 85% at T3. Both PSA positivity rates (range 7.7-8.8% at T0-T3) and DRE positivity rates (range 6.8-7.6% at T0-T3) were relatively constant over time. The positive predictive value (PPV) of a PSA level of >4.0 ng/mL decreased from 17.9% at T0 to 10.4-12.3% at T1-T3; the PPV for DRE (in the absence of a positive PSA test) was constant over time (2.9-3.6%). Cancer was diagnosed in 1902 men (4.9%). Screen-detected cancers at T0 (549) were more likely to be clinical stage III/IV (5.8%) and to have a Gleason score of 7-10 (34%) than screen-detected cancers at T1-T3 (1.5-4.2% stage III/IV and 24-27% Gleason score 7-10 among 1054 cases). CONCLUSION: The present findings on serial prostate screening are similar to those reported from other multi-round screening studies. Determining the effect of PSA screening on prostate cancer mortality awaits further follow-up.

Point: the value of predicting life expectancy in men with clinically localized prostate cancer.

The prediction of life expectancy in prostate cancer screening and treatment is a controversial topic that evokes various opinions regarding its validity. The authors believe incorporating life expectancy prediction into the treatment algorithms for prostate cancer is important. Using a combination of clinical judgment and specific predictive tools, physicians can estimate the life expectancy of patients with prostate cancer. These estimates can then be used to help guide treatment discussion. Estimating life expectancy benefits older men in whom decisions regarding the best form of treatment may be difficult.

Computerized tomographic angiography for renal donor evaluation leads to a higher exclusion rate.

PURPOSE: We compared the exclusion rate for potential living renal donors evaluated with computerized tomography angiography and radionuclide renal scintigraphy (renal scan) vs excretory urogram, renal scan and renal arteriography. MATERIALS AND METHODS: From March 2004 through February 2006, 603 consecutive patients were evaluated as potential living renal donors. From March 2004 through February 2005, 270 consecutive patients underwent evaluation with excretory urogram, renal scan and renal angiography (group 1). Of these patients 16 underwent computerized tomography to evaluate abnormalities detected on excretory urogram. From March 2005 through February 2006, 333 consecutive patients underwent evaluation with computerized tomography angiography and renal scan (group 2). The number of patients excluded for medical reasons and/or radiographic abnormalities was determined for the 2 groups. RESULTS: More than twice as many patients evaluated with computerized tomography were excluded. In group 1, 7% of patients (20 of 270) were excluded from donation due to radiographic findings vs 16% (53 of 333) in group 2 (p=0.0016). Of the patients 26% and 23% were excluded from renal donation for medical reasons in groups 1 and 2, respectively (p=0.5059). CONCLUSIONS: Multidetector row computerized tomography angiography increases the detection of incidental radiographic abnormalities as well as the renal donor exclusion rate. The increased sensitivity of computerized tomography angiography has created a dilemma for those determining patient eligibility for kidney donation because the clinical significance of many of these findings is unclear. Additional studies should address the significance of these incidental findings so that patients are not needlessly excluded from kidney donation.

Prostate volume and prostate-specific antigen levels in men enrolled in a large screening trial.

OBJECTIVES: Prostate volume correlates both with prostate-specific antigen (PSA) values and with the presence of benign prostatic hyperplasia (BPH). Here we examine the relationship between prostate volume and PSA level in a large, geographically diverse sample of men undergoing prostate cancer screening. METHODS: We followed 35,323 men enrolled in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial. Each man was screened with digital rectal examination (DRE) and PSA levels for up to 4 years. Prostate volume was estimated by DRE performed by trained examiners at the PLCO sites. Linear and logistic regression was used to assess the effect of prostate volume and age on PSA levels. Regression coefficients were adjusted for the effect of prostate volume measurement error. RESULTS: Prostate volume estimated by DRE showed considerable measurement error. Averaging volume over screening visits and accounting for examiner bias greatly reduced this error. Linear regression analysis showed a slope of 0.030/cm3 of log PSA on prostate volume when correcting for measurement error (95% confidence interval [CI], 0.029 to 0.031). Age was independently associated with (log) PSA, with a slope of 0.022 per year. Logistic regression analysis of the risk of having an elevated PSA value (exceeding 4 ng/mL) showed an odds ratio of 1.9 (95% CI, 1.8 to 2.0) associated with a 10 cm3 increase in prostate volume. The correlation of log PSA and prostate volume was 0.37. Prostate volume was not correlated with body mass index and showed weak correlation (r = 0.14) with age. CONCLUSIONS: Prostate volume and age are independently associated with increased PSA levels in a population of men undergoing screening.

Supplemental and dietary vitamin E, beta-carotene, and vitamin C intakes and prostate cancer risk.

BACKGROUND: Vitamin E, beta-carotene, and vitamin C are micronutrient antioxidants that protect cells from oxidative damage involved in prostate carcinogenesis. In separate trials, supplemental vitamin E was associated with a decreased risk of prostate cancer among smokers and supplemental beta-carotene was associated with a decreased risk of prostate cancer among men with low baseline plasma beta-carotene levels. METHODS: We evaluated the association between intake of these micronutrient antioxidants from foods and supplements and the risk of prostate cancer among men in the screening arm of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. At baseline, trial participants completed a 137-item food frequency questionnaire that included detailed questions on 12 individual supplements. Cox proportional hazards models were used to estimate relative risks (RRs) and 95% confidence intervals (CIs). All statistical tests were two-sided. RESULTS: We identified 1338 cases of prostate cancer among 29 361 men during up to 8 years of follow-up. Overall, there was no association between prostate cancer risk and dietary or supplemental intake of vitamin E, beta-carotene, or vitamin C. However, among current and recent (i.e., within the previous 10 years) smokers, decreasing risks of advanced prostate cancer (i.e., Gleason score > or = 7 or stage III or IV) were associated with increasing dose (RR for > 400 IU/day versus none = 0.29, 95% CI = 0.12 to 0.68; Ptrend = .01) and duration (RR for > or = 10 years of use versus none = 0.30, 95% CI = 0.09 to 0.96; Ptrend = .01) of supplemental vitamin E use. Supplemental beta-carotene intake at a dose level of at least 2000 microg/day was associated with decreased prostate cancer risk in men with low (below the median of 4129 microg/day) dietary beta-carotene intake (RR = 0.52, 95% CI = 0.33 to 0.81). Among smokers, the age-adjusted rate of advanced prostate cancer was 492 per 100,000 person-years in those who did not take supplemental vitamin E, 153 per 100,000 person-years in those who took more than 400 IU/day of supplemental vitamin E, and 157 per 100,000 person-years in those who took supplemental vitamin E for 10 or more years. Among men with low dietary beta-carotene intake, the age-adjusted rate of prostate cancer was 1122 per 100,000 person-years in those who did not take supplemental beta-carotene, and 623 per 100,000 person-years in those who took at least 2000 microg/day of supplemental beta-carotene. CONCLUSIONS: Our results do not provide strong support for population-wide implementation of high-dose antioxidant supplementation for the prevention of prostate cancer. However, vitamin E supplementation in male smokers and beta-carotene supplementation in men with low dietary beta-carotene intakes were associated with reduced risk of this disease.

Preoperative biofeedback assisted behavioral training to decrease post-prostatectomy incontinence: a randomized, controlled trial.

PURPOSE: We tested the effectiveness of preoperative biofeedback assisted behavioral training for decreasing the duration and severity of incontinence, and improving quality of life in the 6 months following radical prostatectomy. MATERIALS AND METHODS: We performed a prospective, randomized, controlled trial comparing preoperative behavioral training to usual care. The volunteer sample included 125 men 53 to 68 years old who elected radical prostatectomy for prostate cancer. Patients were stratified according to age and tumor differentiation, and randomized to 1 preoperative session of biofeedback assisted behavioral training plus daily home exercise or a usual care control condition, consisting of simple postoperative instructions to interrupt the urinary stream. The main outcome measurements were duration of incontinence (time to continence), as derived from bladder diaries, incontinence severity (the proportion with severe/continual leakage), pad use, Incontinence Impact Questionnaire, psychological distress (Hopkins Symptom Checklist) and health related quality of life (Medical Outcomes Study Short Form Health Survey). RESULTS: Preoperative behavioral training significantly decreased time to continence (p = 0.03) and the proportion of patients with severe/continual leakage at the 6-month end point (5.9% vs 19.6%, p = 0.04). There were also significant differences between the groups for self-reported urine loss with coughing (22.0% vs 51.1%, p = 0.003), sneezing (26.0% vs 48.9%, p = 0.02) and getting up from lying down (14.0% vs 31.9%, p = 0.04). No differences were found on return to work and usual activities or quality of life measures. CONCLUSIONS: Preoperative behavioral training can hasten the recovery of urine control and decrease the severity of incontinence following radical prostatectomy.

A prospective study of lycopene and tomato product intake and risk of prostate cancer.

BACKGROUND: Dietary lycopene and tomato products may reduce risk of prostate cancer; however, uncertainty remains about this possible association. METHODS: We evaluated the association between intake of lycopene and specific tomato products and prostate cancer risk in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, a multicenter study designed to investigate cancer early detection methods and etiologic determinants. Participants completed both a general risk factor and a 137-item food frequency questionnaire at baseline. A total of 1,338 cases of prostate cancer were identified among 29,361 men during an average of 4.2 years of follow-up. RESULTS: Lycopene intake was not associated with prostate cancer risk. Reduced risks were also not found for total tomato servings or for most tomato-based foods. Statistically nonsignificant inverse associations were noted for pizza [all prostate cancer: relative risk (RR), 0.83; 95% confidence interval (95% CI), 0.67-1.03 for >or=1 serving/wk versus < 0.5 serving/mo; P(trend)=0.06 and advanced prostate cancer: RR, 0.79; 95% CI, 0.56-1.10; P(trend)=0.12] and spaghetti/tomato sauce consumption (advanced prostate cancer: RR=0.81, 95% CI, 0.57-1.16 for >or=2 servings/wk versus<1 serving/mo; P(trend)=0.31). Among men with a family history of prostate cancer, risks were decreased in relation to increased consumption of lycopene (P(trend)=0.04) and specific tomato-based foods commonly eaten with fat (spaghetti, P(trend)=0.12; pizza, P(trend)=0.15; lasagna, P(trend)=0.02). CONCLUSIONS: This large study does not support the hypothesis that greater lycopene/tomato product consumption protects from prostate cancer. Evidence for protective associations in subjects with a family history of prostate cancer requires further corroboration.

Retrograde stenting for obstruction of the renal transplant ureter.

OBJECTIVES: To present our experience with retrograde stent placement and stent exchange for transplant ureteral obstruction. METHODS: A review of our renal transplant database was performed to identify all renal transplant patients who underwent attempted retrograde ureteral stenting for allograft ureteral obstruction or attempted allograft ureteral stent exchange between May 1992 and April 2004. A retrospective review was performed. RESULTS: Forty patients underwent 52 attempted retrograde ureteral stent placements, and 11 patients underwent a total of 27 attempted stent exchanges. In patients with ureteral obstruction, the most common clinical signs and symptoms were nausea, vomiting, diarrhea, abdominal pain, fever, decreased urine output, edema, and an elevated serum creatinine. Of the 52 cases of allograft ureteral obstruction and attempted retrograde ureteral stent placement, 28 (53.8%) were managed successfully with retrograde ureteral stenting. Of the 27 attempted stent exchange procedures, a successful exchange was accomplished in 23 cases (85.2%). CONCLUSIONS: Cystoscopy with retrograde allograft stent placement is a reasonable first approach to the management of transplant ureteral obstruction and is successful in more than one half of cases.

Comorbidity independently predicted death in older prostate cancer patients, more of whom died with than from their disease.

OBJECTIVE: The purpose of this study was to examine the proportion of men who died from prostate cancer (PrCa) vs. with PrCa and assess the comorbid conditions associated with other-cause deaths. STUDY DESIGN AND SETTING: We identified all male decedents aged >/=65 years in Jefferson County, AL, in 1993-1995. By crosslinking three databases (death certificate, Medicare, and Veteran's Administration), we identified men whose deaths might have been caused by PrCa. We abstracted and reviewed medical records to rate comorbid conditions and determine whether or not death was due to PrCa. RESULTS: Of 561 men with a premortem diagnosis of PrCa, 42% died from PrCa and 53% died with PrCA; 50.2% of blacks died from PrCa vs. 36.9% of Whites. Other factors related to dying with PrCa included older age at death and a serious, or very serious, comorbid condition. Treatment did not have an independent effect on cause of death (i.e., death with vs. from PrCa). CONCLUSIONS: Comorbidity was an independent predictor of dying with PrCa, even after adjustment for ethnicity, age, and treatment. Given the as yet unproven benefit of PrCa screening, our results extend the body of information relevant to the screening decision; among men dying with a diagnosis of PrCa, only about 1/3 to 1/2 died from the disease.

Donor nephrectomy: A comparison of techniques and results of open, hand assisted and full laparoscopic nephrectomy.

PURPOSE: Laparoscopic donor nephrectomy (LAP) has been gaining more popularity among kidney donors and transplant surgeons. There have been some concerns about the function of kidney grafts harvested by laparoscopic procedures. We report our results of LAP. MATERIALS AND METHODS: Prospective data were collected for our donor nephrectomy operations. A telephone survey was done by an independent investigator on the impact of surgery on quality of life. Graft function was also evaluated by serial serum creatinine and mercaptoacetyltriglycine renal nuclear scans. RESULTS: A total of 100 patients were included in the study; of whom 55 underwent open donor nephrectomy (OD), 28 underwent LAP and 17 underwent hand assisted donor nephrectomy (HAL). Mean patient age was 39 +/- 12 years and it was similar in all groups. Mean operative time was 306 +/- 40 minutes for LAP, 294 +/- 42 minutes for HAL and 163 +/- 24 minutes for OD (p = 0.001). Laparoscopic operative time was decreased to 180 +/- 56 minutes for LAP and 155 +/- 40 minutes for HAL in the last 10 patients. Mean estimated blood loss was 200 +/- 107 cc for LAP, 167 +/- 70 cc for HAL and 320 +/- 99 cc for OD (p = 0.0001). Mean warm ischemia time was 3 +/- 2 minutes for LAP, 2 +/- 2 minutes for HAL and 2 +/- 1 minutes for OD (p = 0.002). Postoperative hospitalization was 2 +/- 2 days for LAP and 3 +/- 2 days for OD (p = 0.01). LAP required 30% less narcotic medicine than OD postoperatively (p = 0.04). There were no major complications in LAP cases and no complete or partial graft loss was noted. Mean followup was 7 months. Recipient creatinine was not significantly different for kidneys harvested by LAP or OD (p = 0.5). Diuretic mercaptoacetyltriglycine renograms were performed in all recipients 1 to 3 days after surgery and mean effective renal plasma flow was similar for the 3 groups (p = 0.9). According to telephone survey results 85% of LAP, 71% of HAL and 43% of OD patients reported a return to normal physical activity within 4 weeks after surgery. Similarly 74% of LAP, 62% of HAL and 26% of OD patients were able to return to work within 4 weeks after surgery. CONCLUSIONS: Our data show no significant difference in graft function between LAP and OD. LAP and HAL were safe and complications were minimal. The main difference was that patients treated with LAP and HAL returned to normal physical activity and work significantly earlier than those who underwent OD.