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Prostate studies focus on barriers to early diagnosis, candidates for conservative treatment, and urinary tract symptoms

Physicians diagnosed prostate cancer in about 200,000 American men in 1998. Uncertainty exists about whether routine prostate-specific antigen (PSA) testing should be recommended to improve early diagnosis of prostate cancer. Also, it remains unclear whether patients benefit more from aggressive treatments such as surgery and radiation treatment or a more conservative approach of watchful waiting followed by androgen suppression for symptomatic metastatic disease. Finally, many men remain confused about the relationship between genitourinary symptoms and prostate cancer.

Researchers supported by the Agency for Health Care Policy and Research recently published three studies on these issues. The first study (National Research Service Award fellowship F32 HS00125) suggests that illiteracy is a major barrier to PSA screening and early prostate cancer diagnosis among black men. The second study, by the Prostate Patient Outcomes Research Team (HS08397), shows that men with high-grade prostate tumors are less likely to benefit from conservative treatment than those with low-grade tumors. The third study, also by the Prostate PORT, shows a high prevalence of bothersome genitourinary symptoms in men 18 to 50 years of age and a high proportion of men who worry that these symptoms may be related to prostate cancer.

Bennett, C.L., Ferreira, M.R., Davis, T.C., and others. (1998). "Relation between literacy, race, and stage of presentation among low-income patients with prostate cancer." Journal of Clinical Oncology 16(9), pp. 3101-3104.

Black men are almost twice as likely as white men to be initially diagnosed with advanced-stage prostate cancer. But it is their higher level of illiteracy, not black race, that seems to be a barrier to early cancer diagnosis, according to the authors of this study. Low-income black men are probably not aware of the need to undergo prostate cancer screening nor of the availability of screening at churches, schools, clinics, and hospitals, explain the researchers. They evaluated literacy and prostate cancer stage at diagnosis in 212 low-income men who received medical care at equal-access sites in two different cities. The researchers developed a model to evaluate predictors of metastatic prostate cancer at presentation as a function of patient age, race, literacy, and city.

Half of black men were diagnosed with advanced-stage disease compared with 36 percent of white men. Also, black men were nearly six times more likely to have literacy levels less than sixth grade (52 percent vs. 9 percent). Men with metastatic cancer at diagnosis were 1.5 times more likely to have lower literacy levels (less than sixth grade for 40 percent with stage D vs. 25 percent for stages A to C). After adjustment for differences in literacy, age, and city, race was not a significant predictor of advanced-stage prostate cancer.

Illiterate blacks may lack adequate knowledge of prostate cancer screening and early detection efforts, many of which are highlighted in written media or presented in materials that are often written at a literacy level above that of a significant portion of the American population. The researchers conclude that culturally sensitive, low-literacy educational materials developed in collaboration with the target population may improve patient awareness of prostate cancer and decrease racial variations in stage of prostate cancer at diagnosis.

Albertsen, P.C., Hanley, J.A., Gleason, D.F., and Barry, M.J. (1998). "Competing risk analysis of men aged 55 to 74 years at diagnosis managed conservatively for clinically localized prostate cancer." Journal of the American Medical Association 280(11), pp. 975-980.

This study demonstrates that men whose prostate biopsy specimens show Gleason score 2 to 4 disease (low-grade or highly differentiated tumor) face a minimal risk of death from prostate cancer within 15 years of diagnosis. Conversely, men whose biopsy specimens show Gleason score 7 to 10 disease (high-grade or poorly differentiated tumor) face a high risk of death from prostate cancer when treated conservatively, even when cancer is diagnosed as late as age 74. Men with Gleason score 5 or 6 disease face a modest risk of death from prostate cancer that increases slowly over at least 15 years of followup.

These findings are based on risk analysis of 767 men (aged 55 to 74 years at diagnosis) with localized prostate cancer diagnosed between 1971 and 1984, either not treated or treated with immediate or delayed hormonal therapy. They were followed for 10 to 20 years after diagnosis. Based on data gathered from patients' medical charts, the researchers estimated the probability of dying from prostate cancer or other causes given the patients' tumor histology and age at diagnosis.

The risk of dying from prostate cancer within 15 years (depending on their age at diagnosis) was 4 to 7 percent for men whose tumors had Gleason scores of 2 to 4, 6 to 11 percent for a score of 5, 18 to 30 percent for a score of 6, 42 to 70 percent for a score of 7, and 60 to 87 percent for a score of 8 to 10. A majority of the younger men in this study with Gleason 2 to 4 tumors are still alive but face a possibility of death from prostate cancer in the future. In contrast, most older men with Gleason 2 to 4 tumors have died from other medical causes rather than prostate cancer. Men with tumors with Gleason scores 7 to 10 experienced a very high rate of death from prostate cancer regardless of their age at diagnosis. Very few of these men of any age were alive 15 years later, with most dying from prostate cancer.

Collins, M.M., O'Leary, M.P., and Barry, M.J. (1998). "Prevalence of bothersome genitourinary symptoms and diagnoses in younger men on routine primary care visits." Urology 52, pp. 422-427.

Half of younger men visiting primary care physicians (PCPs) experience bothersome genitourinary (GU) symptoms. One-fourth of these men worry that their GU symptoms may be related to prostate cancer, according to this study. This finding alone supports the need for PCPs to address the issue of GU symptoms with their younger male patients to educate them about prostate cancer, recommend the researchers.

They gave a self-administered survey to 101 men (mean age of 36 years) visiting a primary care group practice. The survey included the American Urological Association Symptom Index, a benign prostatic hyperplasia (BPH) impact index, as well as additional questions about GU pain, sexual dysfunction, and history of GU diseases. The researchers then reviewed the medical records of men with GU symptoms.

Half of these men reported GU symptoms, 27 percent of all men reported a history of at least one GU disease, and 17 percent had more than one; 16 percent of men had been to a urologist. Ninety percent of all men thought that PCPs should routinely ask younger men GU questions as part of their general health care.

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