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Diagnosis, management, quality of life, and long-term survival in prostate cancer patients: A study based on national, regional, and local cancer registry data in Sweden
Linköping University, Department of Biomedicine and Surgery, Urology. Linköping University, Faculty of Health Sciences.
2001 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Prostate cancer is a common disease with considerable variaton in clinical behaviour and therapeutic responsiveness. Uncertainty surrounds almost all aspects of prostate cancer management and it has been difficult to conduct proper randomised controlled trials required for reliable evidence-based decision-making. Although randomised controlled trials are under way and may eventually provide unbiased data on the efficacy of the management of prostate cancer in selected patient groups under optimal circumstances, population-based studies are necessary to evaluate variations in incidence and the effectiveness of management as practised in the community at large.

This study uses three prospectively assembled population-based cohorts and one cross-sectional group of men with prostate cancer:

1. a local register of all men with prostate cancer in the Central District of Östergotland 1974-1986 (n=813)

2. the South-East Region Prostate Cancer Register 1987-1996 (n=6782)

3. the National Prostate Cancer Register 1996-1997 (n=8328)

4. A cross-sectional group of all men with prostate cancer residing in Östergotland 1999 comprising patients from cohorts 1 and 2 (n=1442)

The incidence of prostate cancer in the South-East Region increased from 613 in 1987 to 780 in 1993 and then slowly declined. The age-adjusted incidence varied from 89/100 000 to 169/100 000 between the different counties included in the National Prostate Cancer Register 1996. In counties where a large percentage of the tumours were detected when still localised, the incidence was higher and the men younger at diagnosis (both p<0.05). In the age interval 50-59 years of age the median PSA was 13 ng/ml, whereas it was 35 ng/ml in those younger than 50. This difference was significant (p<0.05) and is probably explained by larger total tumour volume among men in the youngest age group. For men with well to moderately differentiated tumours and PSA < 20 ng/ml the risk for regional and distant metastases was below 10%. Between 1987 and 1996 the proportion of men treated with radical prostatectomy in the South-East Region decreased from 11% to 2.5%. During the same period the percentage of patients receiving GnRH-analogues increased from 3.9% to 37.8% while the percentage of patients treated with orchiectomy decreased from 40.0% to 12.8%. For patients treated with radiotherapy the median PSA was 16.7 ng/ml, for those who underwent radical prostatectomy 9.3 ng/ml, for patients receiving GnRH-analogues 61 ng/ml and for those treated with bilateral orchiectomy it was 88 ng/ml. All differences in PSA levels between the treatment groups were significant (p<0.05), indicating that there is a selection process with men having less advanced cancer receiving GnRH-analogues and men with more advanced cancer undergoing bilateral orchiectomy, and similarly a selection of men with smaller tumours being treated with radical prostatectomy rather than radiotherapy. Of the men answering the questionnaire sent to all prostate cancer patients residing in Ostergotland 1999 42% had perceived pain during the previous week and 26% stated their quality of life to be 50% or less on a visual analogue scale. A high health-care availability rating and short time since diagnosis were found to significantly predict lower rating of pain on average (p<0.05). Pain on average was found to be a significant predictive factor for decreased quality of life together with high age, low healthcare availability rating and palliative treatment (p<0.05). Age ≥ 70 years, advanced stage and poor differentiation were risk factors associated with increased risk for prostate cancer death in Östergotland Central District Cohort (p<0.05). The survival curve followed a continuous exponential course throughout the period of observation.

The geographical as well as temporal variations in incidence are probably explained by differences in diagnostic activity, which also affects the age at diagnosis and distribution of stages. There are also large disparities in management within the country, which reflects the lack of evidence supporting one treatment in favour of another. How diagnostic activity and different local habits in management affect outcome in the long run is still unknown, but the results of our study regarding quality of life and survival may be used as a basis for management decision-making. Patients with localised tumours have a favourable prognosis, even without initial treatment. When deciding on therapy, however, the grade of malignancy should be taken into account as it has a great influence on disease-specific survival. For men with well to moderately differentiated tumours and PSA < 20 ng/ml, further investigation to exclude distant and regional metastases is unnecessary.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet , 2001. , 94 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 664
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-25708Local ID: 10084ISBN: 91-7219-765-X (print)OAI: oai:DiVA.org:liu-25708DiVA: diva2:246256
Public defence
2001-04-06, Berzeliussalen, Universitetssjukhuset, Linköping, 09:00 (Swedish)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-09-05Bibliographically approved
List of papers
1. Prostate Cancer Registration in Four Swedish Regions 1996: Differences in Incidence, Age Structure and Management
Open this publication in new window or tab >>Prostate Cancer Registration in Four Swedish Regions 1996: Differences in Incidence, Age Structure and Management
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1999 (English)In: Scandinavian Journal of Urology and Nephrology, ISSN 0036-5599, E-ISSN 1651-2065, Vol. 33, no 5, 306-311 p.Article in journal (Refereed) Published
Abstract [en]

Introduction: In 1996 registration of prostate cancer in four of the six Swedish regions was started to facilitate evaluation of geographical variations in incidence and treatment.

Material and methods: For all cases of prostate cancer, personal identification number, tumour stage, tumour grade and primary treatment were registered.

Results: In the four regions covered by the register, 3541 cases of prostate cancer were registered. Altogether there were 5795 cases of prostate cancer diagnosed in Sweden the same year. The age-standardized incidence varied from 89/100 000 to 169/100 000 among counties. The proportion of localized tumours correlated positively to the incidence (p &lt; 0.05) and negatively to mean age at diagnosis (p &lt; 0.01). There was also a significant positive correlation between the proportion of localized tumours and the percentage of patients given curative treatment. All registered variables showed large geographical variations, especially concerning percentage of T1c tumours, treatment of localized tumours and choice of palliative treatment.

Conclusion: Diagnostic activity varied considerably among counties, resulting in large variation in age-standardized incidence. High incidence is associated with a larger proportion of localized tumours, which, in turn, is associated with early age at diagnosis. In counties where a policy of detecting tumours early is practised, curative treatment is also given more often. Treatment of localized tumours and preference for palliative treatment seem to depend on local traditions. The lack of cytological and histopathological standards makes geographical comparisons based on tumour grade impossible.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25344 (URN)10.1080/003655999750017374 (DOI)9786 (Local ID)9786 (Archive number)9786 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
2. Prostate carcinoma trends in three counties in Sweden 1987–1996
Open this publication in new window or tab >>Prostate carcinoma trends in three counties in Sweden 1987–1996
2000 (English)In: Cancer, ISSN 0008-543X, E-ISSN 1097-0142, Vol. 88, no 6, 1445-1453 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND To detect changes in the incidence rate and management of prostate carcinoma, all cases of the disease diagnosed in the southeast region of Sweden between 1987–1996 were recorded.

METHODS The register is based on Swedish personal registration numbers, thereby minimizing the number of dropouts. All cases of prostate carcinoma detected in the southeast region have been recorded according to a defined protocol that has been updated successively to match recent views regarding the disease. To ensure a high number of presented cases, the National Cancer Register was checked for missing cases.

RESULTS Six thousand seven hundred eighty-two cases of prostate carcinoma were registered in the region between 1987–1996. The age-adjusted incidence rate reached a peak in 1993, followed by a slight decrease. The mean age at diagnosis throughout the period was 74.2 years, with a peak age of 74.8 years in 1992. The number of incidental tumors followed the development of the number of transurethral resections of the prostate performed in the region, with a peak in 1991. The percentage of patients receiving gonadotropin-releasing hormone (GnRH) analogues increased from 3.9% to 37.8% whereas the percentage of patients treated with orchiectomy decreased from 40.0% to 12.8% and the percentage of those treated with radical prostatectomy decreased from 11.1% to 2.5%.

CONCLUSIONS A diminishing pool of latent tumors may explain the decreasing incidence rate and lower age at diagnosis observed after 1993. Orchiectomy is rapidly being superceded by GnRH analogues. In contrast to trends reported in the U.S., the percentage of men with prostate carcinoma undergoing total prostatectomy appears to be declining in Sweden.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-24995 (URN)10.1002/(SICI)1097-0142(20000315)88:6<1445::AID-CNCR24>3.0.CO;2-T (DOI)9415 (Local ID)9415 (Archive number)9415 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
3. Prostate-Specific Antigen for Prostate Cancer Staging in a Population-based Register
Open this publication in new window or tab >>Prostate-Specific Antigen for Prostate Cancer Staging in a Population-based Register
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2002 (English)In: Scandinavian Journal of Urology and Nephrology, ISSN 0036-5599, E-ISSN 1651-2065, Vol. 36, no 2, 99-105 p.Article in journal (Refereed) Published
Abstract [en]

Objective: Previous studies have shown a relationship between serum prostate-specific antigen (PSA) level and prostate tumour volume. Reports based on selected case series have also indicated that serum PSA may be used for staging, although a varying prevalence of metastasizing tumours complicates the interpretation of these studies. In order to determine the accuracy of the serum level of PSA in predicting the presence of metastases we performed a prospective cohort study of a geographically defined population of men with prostate cancer.

Methods: Serum level of PSA and the results of investigations for regional lymph node and distant metastases were recorded for all 8328 men with prostate cancer registered in the Swedish National Prostate Cancer Register 1996-1997.

Results: The prevalence of lymph node metastases among men who had undergone lymph node exploration was 4%, 16% and 33% for well, moderately and poorly differentiated tumours. The corresponding prevalence of distant metastases was 12%, 30% and 48%. With serum PSA <20 ng/ml as a cut-off point the negative likelihood ratios for well and moderately differentiated tumours were found to be 0.47 and 0.45 for lymph node metastases and 0.24 and 0.18 for distant metastases, resulting in post-test probabilities >92% for the exclusion of metastases. In men with poorly differentiated tumours, the negative likelihood ratio would need to be even lower to safely exclude disseminated disease.

Conclusion: For well to moderately differentiated tumours, further investigations to assess the presence of metastases may be omitted with no great risk for understaging if serum PSA <20 ng/ml.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25341 (URN)10.1080/003655902753679373 (DOI)9783 (Local ID)9783 (Archive number)9783 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
4. Prostate-specific Antigen as Surrogate for Characterizing Prostate Cancer Subgroups
Open this publication in new window or tab >>Prostate-specific Antigen as Surrogate for Characterizing Prostate Cancer Subgroups
Show others...
2002 (English)In: Scandinavian Journal of Urology and Nephrology, ISSN 0036-5599, E-ISSN 1651-2065, Vol. 36, no 2, 106-112 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To evaluate how serum prostate-specific antigen (PSA) levels in a population-based cohort of men with prostate cancer vary with age and intensity in the diagnostic activity and to describe the treatment selection processes associated with PSA level.

Material and Methods: All men in the Swedish National Prostate Cancer Register diagnosed during 1996-1997 were included. In 1996 the register included 19 counties, covering 61% of the Swedish male population, and in 1997 21 counties with 79% of the Swedish male population.

Results: A total of 8328 men were registered. PSA levels were missing in 341 cases. With increasing PSA there was a shift towards more advanced and poorly differentiated tumours. PSA at diagnosis increased with age, with the exception of patients younger than 50 years who had higher PSA values. The mean logarithm of PSA correlated negatively with the percentage of localized tumours ( p < 0.005) and the age-adjusted incidence ( p < 0.05) in each respective county in 1997. PSA was higher in men receiving radiotherapy compared with those treated with radical prostatectomy as well as in the group treated with bilateral orchiectomy compared with those receiving GnRH-analogues.

Conclusions: If PSA is used as a surrogate measure of extent of tumour volume in a population of prostate cancer patients, our findings indicate that age distribution and differences in incidence (possibly due to variation in diagnostic activity) should be taken into account. In our cohort there was a selection process, probably in part guided by PSA level, when choosing type of curative or palliative treatment.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25340 (URN)10.1080/003655902753679382 (DOI)9782 (Local ID)9782 (Archive number)9782 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
5. Pain and health-related quality of life in a geographically defined population of men with prostate cancer
Open this publication in new window or tab >>Pain and health-related quality of life in a geographically defined population of men with prostate cancer
2001 (English)In: British Journal of Cancer, ISSN 0007-0920, E-ISSN 1532-1827, Vol. 85, no 4, 497-503 p.Article in journal (Refereed) Published
Abstract [en]

In order to provide baseline data on pain and health-related quality of life, to explore factors predicting pain and reduced quality of life, and to find potentially undertreated cases in men with prostate cancer, we undertook a population-based questionnaire study. The questionnaire, which included the EuroQo1 instrument, the Brief Pain Inventory form and 8 specially designed questions, was sent to all men with prostate cancer in the county of ╓sterg÷tland, Sweden. Of the 1442 men included in the study, 1243 responded to the questionnaire. Altogether 42% had perceived pain during the previous week and 26% stated their quality of life to be 50% or lower on a visual analogue scale. A high rating of health care availability and short time since diagnosis were found to significantly predict lower ratings of pain (P < 0.05). Pain was found to be a significant predictive factor for decreased quality of life together with high age, low rating of health care availability and palliative treatment (P < 0.05). In conclusion, assessment and treatment of pain is essential for a good quality of life in men with prostate cancer. The monitoring of prostate cancer patients should be individualized to fit the demands of the groups with the greatest need for support.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25343 (URN)10.1054/bjoc.2001.1965 (DOI)9785 (Local ID)9785 (Archive number)9785 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
6. Long-term survival in a swedish population-based cohort of men with prostate cancer
Open this publication in new window or tab >>Long-term survival in a swedish population-based cohort of men with prostate cancer
2000 (English)In: Urology, ISSN 0090-4295, E-ISSN 1527-9995, Vol. 56, no 3, 442-447 p.Article in journal (Refereed) Published
Abstract [en]

Objectives. To study the long-term survival of patients with prostate cancer, determine the risk factors for prostate cancer death, and investigate the outcome of initially untreated localized prostate cancer and incidentally detected tumors.

Methods. The survival of 813 patients in a population-based cohort of patients with prostate cancer in Linköping, Sweden, diagnosed from 1974 to 1986, was analyzed.

Results. At 10, 15, and 20 years after diagnosis, the prostate cancer-specific survival rate of men with localized, initially untreated, prostate cancer was 85.0% (95% confidence interval [CI], 79.0% to 91.0%), 80.0% (95% CI, 72.5% to 87.5%), and 62.6% (95% CI, 43.0% to 82.2%). Age 70 years or older, advanced stage, and poor differentiation were risk factors associated with an increased risk of prostate cancer death. At 10 years, the prostate cancer-specific survival rate among men with localized tumors treated by expectancy was 90% (95% CI, 84% to 97%) for grade 1 tumors, 74% (95% CI, 60% to 89%) for grade 2 tumors, and 59% (95% CI, 29% to 90%) for grade 3 tumors. For patients with incidentally detected tumors, the grade of malignancy was a more important risk factor than tumor volume.

Conclusions. Patients with localized tumors have a favorable prognosis, even without initial treatment. However, when deciding on therapy, the grade of malignancy should be taken into account, as it has a great influence on survival. We did not see a tendency toward increased mortality when the patients were followed up for longer than 10 years after diagnosis.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-24993 (URN)10.1016/S0090-4295(00)00696-8 (DOI)9413 (Local ID)9413 (Archive number)9413 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved

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