geoffrey modest medical blogs

  A Swedish study found that following men with a high PSA with an MRI seemed to be a reasonable approach for risk-stratifying patients, decreasing false positive results and without leading to significant delays in diagnosis of significantprostate cancer, in the Gothenburg-2 trial, a large, population-based, screening trial (see psa MRI followup NEJM2024  in dropbox, or DOI:10.1056/NEJMoa2406050). Special thanks to Brittany Berk (a really smart urologist and, it just so happens, my daughter-in-law) for some comments and suggestions.....   Details: -- about 80,000 men who were 50 to 60 years of age in Gothenburg (aka “Goteborg”), Sweden were eligible for participation in the trial, from which 38,316 men were randomly selected and invited for screening, a population-based trial that started in 2015 -- those who accepted the invitation were assigned in a 1:1:1 manner to 1 of 3 groups:     -- those with low PSA levels of 1.8-3.0 ng/mL....

 A new systematic review and meta-analysis found that digital rectal exam (DRE) did not add any useful information about detecting prostate cancer above and beyond that of PSA (prostate-specific antigen) screening (see prostate ca DRE adds little EurUrolOnc2024 in dropbox, or doi.org/10.1016/j.euo.2023.12.005)   Details : -- a general search was done in August 2023 identifying prospective studies simultaneously investigating the diagnostic performance of DRE and PSA for prostate cancer (PCa) screening -- eight studies were identified including 85,738 participants, three were randomized controlled trials and five were prospective diagnostic studies, all reporting the positive predictive value (PPV) and cancer detection rate (CDR) of both DRE and PSA for the same cohort of patients     -- studies were excluded if they did not have original patient data or were not formal studies, if they did not conduct both DRE and PSA on that same cohort, if they enrolled participant...

The 19.5 year follow-up of the PIVOT study (Prostate Cancer Intervention vs Observation Trial) confirmed their prior observations at the 12-year mark, showing that for men with localized prostate cancer, surgery was not significantly associated with decreases in all-cause or prostate cancer specific mortality (see  prostate ca localized  obs  as good as  surg  NEJM2017  in  dropbox , or Wilt TJ. N  Engl  J Med 2017;377:132). Details: -- From 1994 to 2002, 731 men with localized prostate cancer were randomized to radical prostatectomy vs observation. This study provides patient-reported outcomes data through 2014 -- Mean age at the beginning of the study was 67, PSA 7.8. All patients had to have histologically-confirmed, clinically localized prostate cancer (stage TI-T2NxM0) of any grade diagnosed in the prior 12 months, and PSA needed to be <50, age <75, negative results on bone scan for meta...

this article was sent to me by gordy schiff. interesting study of perceptions and suggestions of US radiation oncologists and urologists on the effectiveness of active surveillance for patients with prostate cancer (see  prostate cancer active surveillance. medcare2014  or Med Care 2014;52: 579–585 ). baseline is that there are general concerns that prostate cancer is greatly overtreated, and that active surveillance (AS) is appropriate (and in fact recommended) for low-risk prostate cancer (clinically localized disease, PSA in 4-10 range, Gleason 6 or less). results:     --national survey of radiation oncologists and urologists about perceptions of AS, done from nov 2011 to april 2012, with  717 completing survey     --71.9% thought AS effective and 80% thought it was underused     --BUT  for a case patient of a 60yoM  diagnosed with low-risk prostate cancer,  these specialists recommended radical prostatectomy i...

the  Scandinavian  prostate cancer group study just published their 18 year followup of radical prostatectomy vs watchful waiting in men with localized prostate cancer (study prior to PSA testing, and was largely of men with palpable nodules).  see   prostate ca  scandan  18 yrs  nejm  2014  in  dropbox , or  DOI : 10.1056/ NEJMoa1311593. this follows their 15 year followup published a couple of years ago. in brief,     --695 men with early prostate cancer randomized to surgery vs watchful waiting, followed up to  23.2 years, though overall analysis at 18 year mark:         -- 63 deaths from prostate cancer in surgery group and 99 in watchful waiting (18% vs 29%, RR 0.56), absolute diff of 11% and NNT to prevent one death = 8     --200 deaths from all causes in the surgery group and 247 in the watchful waiting group (56.1% vs 68.9%, RR 0.71, abs diff 12.8%)    ...