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cme: Early Detection of Prostate Cancer
Christof Börgermann, Herbert Rübben
SUMMARY
Introduction: Prostate cancer is the commonest cancer in men. Only the early stages are curable.
Screening is aimed at identifying cancers confined to the prostate. Methods: Discussion of screening in the light of the interdisciplinary guideline and recent literature. Results: Screening is performed annually from the age of 50, ceasing at a life expectancy of less than 10 years. The digital-rectal
examination is supplemented by PSA assay. Prior to the first PSA test informed consent must be
obtained, with full discussion of biopsy and treatment options. A threshold of 4.0 ng/mL is defined
as indication for prostate biopsy. Imaging methods do not outperform screening for prostate cancer.
Discussion: Early detection identifies many latent prostate cancers and patients are at risk of overtreatment. A possible solution is to abandon the current single threshold value for PSA, in favour of
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the evaluation of trends in PSA values.
Key words: prostate cancer, early detection, prostate-specific antigen (PSA), digital-rectal examination
(DRE), transrectal Ultrasound (TRUS), biopsy
P
opulation-based screening for the detection of prostate cancer is defined as the
testing of asymptomatic men at risk of having the disease. Population-based screening is performed on the initiative of the physician, rather than the patient, unlike so-called
opportunistic screening, which is initiated by the patient. Prostate cancer is asymptomatic
in its early stages; only later on does it produce clinical manifestations such as pain,
hematuria, disturbances of urination, or rectal infiltration. There is a high chance of cure
only when the disease is discovered early, while it is still asymptomatic.
Screening for prostate cancer has not yet been conclusively shown to be effective, in
the sense of reducing mortality. Two large randomized studies addressing this issue are
currently in progress, the PLCO study ("Prostate, Lung, Colorectal, and Ovary") in the
USA and the ERSPC study ("European Randomized Screening for Prostate Cancer") in
Europe (1). Data from both studies, comparing the mortality from prostate cancer in
screened men versus unscreened controls, will presumably be available in 2008. Even
though these data are not yet in, there is already a broad consensus among physicians that
screening for prostate cancer with a PSA (prostate-specific antigen) test and digital rectal examination should be provided to all men who request it, after they have given their
informed consent (2).
Epidemiology
Prostate cancer is an illness of old age; it rarely arises in men under age 50 (3). It is the most
common type of newly diagnosed cancer and the second most common cause of death from
cancer in men. Roughly 12,000 men die of prostate cancer in Germany every year (4). Because the population as a whole is growing older, the diagnosis and treatment of prostate
cancer will take on increasing importance in the years to come. By 2050, the number of
persons over age 60 in Germany is expected to rise to 28 million, which will be 37% of the
population, or double the current percentage.
Klinik und Poliklinik für Urologie, Kinderurologie und Urologische Onkologie des Universitätsklinikum Essen (Dr. med. Börgermann, Prof. Dr.
med. Dr. h. c. Rübben)
Population-based screening
The effectiveness of population-based screening
for prostate cancer is unproven.
In Germany, population-based screening
for prostate cancer is not performed.
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The current status of screening
Population-based screening for prostate cancer is now performed only in scientific studies
because the available data do not yet support its universal application. Nonetheless, screening on request is part of routine clinical practice in many countries. The current interdisciplinary consensus in Germany (5) recommends annual screening for prostate cancer in
all men over age 50, or age 45 if there is a family history of the disease. The last screening
is generally performed at age 75, though screening is still recommended for men over age
75 whose life expectancy is long. Life expectancy can be estimated with the aid of various
normograms or algorithms that are available on the Internet; the normograms of Albertsen
et al. (6) have been found useful in this group of patients. Digital rectal palpation alone is
not an adequate screening method for prostate cancer and is therefore performed in combination with measurement of the PSA concentration. Before the first PSA level is obtained,
the patient must be informed of the diagnostic and therapeutic measures that might be
recommended afterward depending on the result, including prostatic biopsy and treatment
of prostate cancer, and of the risks of these procedures. An elevated PSA level should be
confirmed by repeated testing. Possible sources of error, both outside and inside the
laboratory, should be considered and eliminated. Various factors can affect the measured
PSA level and render its interpretation more difficult: circadian variation (up to 30%), instability of the sample (transport time? temperature? serum or whole blood?), external
factors, differences between PSA testing systems, and calibration.
A PSA level of 4.0 ng/ml or higher is currently considered an indication for further investigation with an ultrasound-guided biopsy under antibiotic coverage. Tissue specimens are
taken with a punch at the sites where tumors are most commonly found, i.e., mainly
laterally. At least six specimens are taken; the number depends on the size of the prostate,
as determined by transrectal ultrasonography. The greater the number of specimens, the
higher the chance of detecting prostate cancer.
A second biopsy with at least six tissue specimens is performed within six months, after
the exclusion of all intra- and extraprostatic sources of artifact, in the following situations:
if the findings of the first biopsy are questionable or inconclusive, if no cancer was found
despite a persistently elevated or rising PSA level, or if the first biopsy yielded a histological finding of a high grade PIN (prostatic intraepithelial neoplasia) or ASAP (atypical small
acinar proliferation). Antibiotics are given for two weeks before the second biopsy, and the
PSA level is then measured once again, so that infection can be ruled out as a cause of an
elevated PSA level (Diagram 1). The recommendations outlined above, based on the
current guidelines, are under intense discussion at present; revised recommendations will
be published in the next edition of the guidelines.
Digital rectal examination
Digital rectal examination (DRE) of the prostate is a basic and cost-effective component of
screening for prostate cancer. It has been a recommended procedure since 1971, the year
the German screening program was introduced. Nonetheless, its effectiveness is open to
question. No more than 10 to 15% of prostate cancers with a PSA level below 4.0 ng/ml
can be detected by DRE (7). DRE is thus not a sensitive test, yet the predictive value of a
positive DRE, when the PSA level is below 4.0 ng/ml, is high. Most prostate cancers
detected in this way fulfill the criteria for a clinically significant tumor, and they would have
remained undetected had DRE not been performed (8). A disadvantage of DRE is that
suspicious palpatory findings are associated with cancer that has spread beyond the prostate
in 40 to 70% of cases (regardless of the PSA level) and may therefore no longer be curable.
Current status of screening
Screening from age 50 onward, or from
age 45 in men with a positive family history.
A PSA level above 4 ng/ml is
an indication for a biopsy.
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DIAGRAM 1
Algorithm for prostate cancer screening (S3-guidelines [5])
*1from age 45 onward in patients with positive family history
Transrectal ultrasonography
Transrectal ultrasonography (TRUS) of the prostate is more expensive than DRE and
requires special equipment and training. It is also not universally available. It was thought,
at first, that the use of TRUS to search for echo-poor areas in the prostate might be a good
means of prostate cancer screening, but enthusiasm waned in the light of further data. As
Transrectal ultrasonography
Transrectal ultrasonography is more expensive
than DRE and requires special equipment and training.
It is, however, an indispensable part of the technique
of prostatic punch biopsy.
Treatment algorithm
Patients with PSA > 4 ng/ml and/or a suspect
finding for tumor on DRE should undergo an
ultrasound-guided punch biopsy of the prostate.
Patients with normal results should continue
to have their PSA checked annually.
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reported in an interdisciplinary consensus statement (5), a number of studies have documented the inadequate ability of TRUS to detect localized prostate cancer when used as a
screening technique (9, 10). Recently, attempts have been made to improve the sensitivity
and specificity of TRUS with technical innovations including color-coded duplex ultrasonography, high-resolution Doppler ultrasonography, ultrasonographic contrast media,
B-image harmonic ultrasonography, 3D reconstruction, and the use of neural networks
such as "computed TRUS" (11, 12).
The current recommendations of the American Cancer Society and the European
Association of Urology recognize that TRUS has a role in the diagnostic evaluation of
prostate cancer, but the question of its use in screening remains open. Its most important
application is during the performance of ultrasound-guided punch biopsy of the prostate. It
enables both the systematic removal of cylindrical tissue specimens, and the targeted
sampling of suspect areas.
Punch biopsy of the prostate
According to the current guidelines, any suspect findings on digital rectal examination,
and/or a PSA level that is above 4 ng/ml for unexplained reasons, are considered an indication for punch biopsy of the prostate (provided that the patient's current quality of life and
life expectancy are such that a positive biopsy would be followed by treatment). Punch
biopsy under transrectal ultrasonic guidance is the internationally established standard.
Depending on the size of the organ, at least three tissue samples are taken at various sites in
each of the two prostatic lobes (13). The biopsy must be performed under antibiotic
coverage, preferably with a gyrase inhibitor.
The complications described in the literature include hematuria for more than three days
(22%), hemospermia (50%), fever (3.5%), and urosepsis requiring hospitalization (0.5%) (14).
Prostate-specific antigen
The introduction of routine determination of prostate-specific antigen levels in the late
1980's was a revolutionary development in the early detection of prostate cancer. Screening with PSA levels led to an overall shift in the stage of prostate cancer at the time of detection, from a later to an earlier stage (15). In the pre-PSA era, two-thirds of all prostate
cancers had spread beyond the prostate by the time of detection and were thus no longer
curable. Two-thirds of all prostate cancers are now detected while still confined to the
prostate (16, 17). In the USA, the first country in which PSA testing was used for screening,
the mortality from prostate cancer has fallen since 1991. It is unknown whether this drop is
actually due to more frequent detection in the potentially curable stage when the tumor is
confined to the prostate, or to improvements in therapy, or both. This question will only be
answerable when the results of the large-scale studies of screening for prostate cancer
become available in 2008 (1).
PSA is an organ-specific rather than tumor-specific marker. The serum PSA level can be
influenced not only by malignancy, but by numerous other factors as well:
> medications such as finasteride, luteinizing hormone releasing hormone (LHRH)
analogues, and antiandrogens,
> prostatic diseases such as acute or chronic prostatitis, benign prostatic hyperplasia
(BPH), and urinary retention,
> and urological manipulations such as prostatic punch biopsy and digital rectal examination (18).
Large-scale studies have shown that the PSA level is below 4 ng/ml in 80 to 85% of men
presenting for screening, between 4 and 10 ng/ml in 10 to 15%, and above 10 ng/ml in 2 to
Prostatic punch biopsy
The established standard is a punch biopsy under
transrectal ultrasonographic guidance.
The potential complications include infection, sepsis,
hematuria, and hemospermia.
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DIAGRAM 2
Distribution of PSA values in 11,656 men who presented for prostate cancer screening.
TABLE 1
TABLE 2
The frequency of biopsy-proven
prostate cancer as a function of
the PSA level
The relation between prostatespecific antigen and tumor stage
PSA (ng/mL)
Percentage of
tumors in stage
= pT2(%) *1
6,6
2,5–4,0
78–83
0,6–1,0
10,1
4,1–6,0
74–81
1,1–2,0
17,0
6,1–8,0
71–78
2,1–3,0
23,9
8,1–10,0
67–75
3,1–4,0
26,9
>10,0
49–57
4,0–9,9
27,9
>10,0
57,6
PSA (ng/mL)
Frequency of
prostate cancer (%)
< 0,5
*1Percentage of tumors that are confined to the
prostate among patients with PSA in the indicated
ranges (Carter 1999)
(Thompson 2003 & ERSPC Rotterdam)
5% (Diagram 2). Prostate cancer is found in up to 15% of men with levels below 4 ng/ml,
about 25% of men with levels between 4 and 10 ng/ml, and over 50% of men with levels
above 10 ng/ml (Diagram 3, Table 1). In the last-named group, the very high PSA level is
often associated with spread of the tumor beyond the prostate. Table 2 shows the percentage of detected prostatic tumors that are confined to the prostate, and therefore curable, as a
function of the PSA level (20). Studies are currently underway to determine whether the
diagnostic value of PSA testing can be improved by the use of PSA isoforms, such as the
f/tPSA ratio and cPSA, or by the use of different norms for PSA levels depending on age
Prostate-specific antigen
Currently, because of PSA testing, nearly 70% of
prostate cancers can be detected in a curable stage.
The serum PSA concentration can be influenced by
numerous factors other than cancer.
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DIAGRAM 3
DIAGRAM 4
Course of PSA over 10 years. Patients in whom no tumor is found
have nearly constant PSA levels, while in those with prostate cancer
the PSA level rises steadily over time.
Biopsy findings of patients with PSA levels between 4 and 10 ng/ml.
A carcinoma is found in only one-quarter of all cases; two-thirds of
all biopsies yield normal findings.
and prostatic volume. Although these newer techniques have been found to lower the need
for biopsy substantially, they have not yet found their way into routine clinical practice.
PSA-based screening is currently controversial. In the USA, roughly 226 per 100,000
men over age 65 die of prostate cancer every year. Autopsy studies have shown, however,
that as many as 80% of 70-year-olds have latent prostate cancer, i.e., tumors that will not
cause death. It is feared that PSA-based screening will lead to the detection of large numbers of clinically insignificant tumors (13). The dilemma of screening is that its aim is precisely to find tumors that are small and confined to the prostate, because these tumors have
the greatest chance of cure (21). According to the findings of a Scandinavian study, about
15% of men with prostate cancer who are treated with radical prostatectomy will develop
distant metastases within 10 years, as opposed to about 25% of untreated patients (22). This
means that, in about 75% of patients with known prostate cancer who are merely observed,
there will be no systemic progression of disease for 10 years after the diagnosis, and the
chance that systemic progression will develop is only 10% higher than in patients who
undergo radical prostatectomy. On the one hand, these findings confirm the fear that many
clinically insignificant tumors will be detected and treated; on the other hand, they also confirm that 85% of patients do not develop systemically progressive disease after treatment,
and this figure is 10% higher than in untreated patients.
Imaging studies
Visualization of the prostate with currently available techniques such as computerized
tomography, magnetic resonance imaging, and the imaging methods of nuclear medicine is
Imaging studies
"Computed TRUS": a computer program is used
to make otherwise invisible information visible
through color-coding. Histological sections
of the prostate are correlated with ultrasonic
images from the same patient.
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BOX 1
Screening for Prostate Cancer
At present
Beginning at:
Ending at:
Screening interval:
Biopsy indication:
Possible future
recommendations
Age 50
Age 40
When remaining life expectancy < 10 years
1 year
2 years*
PSA = 4 ng/ml
PSA threshold rising
by 0.5 ng/ml/year
*as long as PSA < 2 ng/ml, otherwise annually
BOX 2
Potential "savings" in comparison with the current screening regime*
Screening interval:
PSA tests:
Biopsies:
Surgery/radiation:
Every two years from age 40 onward
~ 35 %
~ 25 %
~ 12 %
*i.e., standard screening according to (24)
inadequate for the early detection of prostate cancer. The same is true, at present, for 11Ccholine-PET/CT. These techniques currently have no application in screening for prostate
cancer.
Future prospects for PSA-based screening
New guidelines for screening for prostate cancer are now under development and will have
to take the major criticisms of PSA-based screening into account:
> the large number of unnecessary PSA determinations,
> the large number of unnecessary prostatic biopsies,
> and the large number of unnecessary treatments for prostate cancer, as the disease will
often remain stable even if untreated, but can also progress even if treated.
The number of unnecessary PSA determinations might be lowered by a longer interval
between tests. The interval between a positive test and the time that the diagnosis would
have been made if this test had not been performed is called the "leadtime." Screening for
prostate cancer with PSA is associated with a leadtime of 5 to 10 years. In the ERSPC
study, which included 8,350 patients, biopsies were performed for PSA values above a threshold of 3 ng/ml. This resulted in the diagnosis of 412 carcinomas of the prostate.
After a testing interval of 48 months, 18 additional carcinomas were detected, all of which
were in the T1 or T2 stage and therefore potentially curable (23). The available data do not
currently allow a determination of the optimal interval for PSA testing, but annual screening
for patients whose PSA values are low no longer seems reasonable. Prolonging the
interval would reduce the number of PSA tests and biopsies performed, thereby not only
lowering the total cost but also limiting unnecessary impairment of the patients' quality of life.
One study, in which patients with prostate cancer confirmed by prostatic punch biopsy
were actively observed, reveals several possible ways of reducing the number of un-
PSA-based screening
Prostate cancer is present in up to 15% of men with
PSA levels below 4 ng/ml, about 25% of men with levels
between 4 and 10 ng/ml, and over 50% of men with
levels above 10 ng/ml. Levels above 10 ng/ml are often
associated with spread of disease beyond the prostate.
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Major criticisms
– Large number of unnecessary PSA tests
– Large number of unnecessary biopsies
– Large number of unnecessary treatments
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necessary diagnostic tests and treatments. 299 patients considered to be at low risk of
developing further progression of their prostate cancer were not treated, but actively
observed. This meant, in practice, that curative treatment was held in reserve until the
moment that the tumor was seen to be starting to progress. The patients were all over 70
years old and had PSA levels below 15 ng/ml, tumor stage cT2b or better, and Gleason
scores below 7. (Note: The Gleason score has been used since the 1970's and is a measure
of the aggressiveness of prostate carcinoma based on histological features, i.e., a method of
tumor grading. The higher the Gleason score, the more aggressive the tumor. The two most
common tissue patterns seen under the microscope are assigned scores from 1 to 5, and
these scores are then added together to generate a Gleason score from 2 to 10). Progression
was defined by various criteria, among which was a PSA doubling time of less than two
years. After a median follow-up of 55 months, the disease-specific survival was 99%.
60% of patients had no progression and remained under active observation (24). It follows
that the dynamics of PSA levels can be exploited in an early detection program to lessen the
number of biopsies and avoid unnecessary impairment of the patients' quality of life. If a
PSA doubling time of less than two years were to be generally used as a criterion for the performance of punch biopsies, then patients like the 60% percent of men in the study who
remained in the observation group would not have to undergo a biopsy, would not learn
their (clinically irrelevant) diagnosis, and would therefore benefit from a better quality of
life. The time course of the PSA level provides an indication of the aggressiveness of
prostate cancer (Diagram 4). If dynamic PSA testing is to be performed, then the initial
PSA level must be measured at an earlier age than the current guidelines recommend, i.e.,
at an age when the risk of prostate cancer is minimal, so that the first value can serve as a
baseline for the detection of possible future increases. The intelligent use of dynamic PSA
testing prior to invasive diagnostic studies might help distinguish patients requiring early
treatment from others who probably harbor clinically insignificant tumors. The concept of
the rate of increase of PSA has been under study for many years, but no definitive
recommendations for dynamic testing can be made at present.
Conclusion
PSA-based screening for prostate cancer might, in the future, look something like this:
testing would begin at age 40 and end when the patient's predicted life expectancy becomes
less than 10 years. Unnecessary testing could be avoided by prolonging the interval
between PSA tests to 2 years for patients whose PSA level is less than 2 ng/ml. The use of
a rigid PSA threshold of 4 ng/ml for prostatic punch biopsy might give way to a more
dynamic approach, e.g., a threshold that rises by 0.5 ng/ml per year (see Boxes 1 and 2).
Conflict of Interest Statement
The authors declare that no conflict of interest exists according to the Guidelines of the International Committee of Medical Journal Editors.
Manuscript received on 19. April 2006, final version accepted on 17. Juli 2006.
Translated from the original German by Ethan Taub, M.D.
REFERENCES
1. De Koning HJ, Liem MK, Baan CA et al.: Prostate cancer mortality reduction by screening: power and time frame
with complete enrollment in the European Randomised Screening for Prostate Cancer (ERSPC) trial. Int J Cancer
2002; 98: 268–73.
2. Schmid HP, Riesen W, Prikler L: Update on screening for prostate cancer with prostate-specific antigen. Crit Rev
Oncol Hematol 2004; 50: 71–8.
3. Pienta KJ: Etiology, epidemiology and prevention of carcinoma of the prostate. In: Walsh PC, Retik A, Stamey TA,
Vaughan EJ, Hrsg.: Campell´s Urology. Philadelphia: Saunders, 1997: 2489–96.
Biopsy findings
Among men with PSA levels between
4 and 10 ng/ml, biopsy reveals
prostate cancer in only one-quarter
of all cases.
Proposal
The elimination of a rigid PSA threshold in favor of a more
dynamic view of PSA levels might help reduce the number
of unnecessary diagnostic and therapeutic procedures and
thereby improve patients' quality of life.
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4. Statistisches Bundesamt. www.destatis.de/basis/d/gesu/gesutab20.php
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6. Albertsen PC, Fryback DG, Storer BE, Kolon TF, Fine J: The impact of co-morbidity on life expectancy among men
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7. Luboldt H, Rubben H: PSA – Früherkennung des Prostatakarzinoms. Urologe A 2000; 39: 22–6.
8. Carvalhal GF, Smith DS, Mager DE, Ramos C, Catalona WJ: Digital rectal examination for detecting prostate cancer at prostate specific antigen levels of 4 ng/mL or less. J Urol 1999; 161(3): 835–9.
9. Ellis WJ, Chetner MP, Preston SD, Brawer MK: Diagnosis of prostatic carcinoma: the yield of serum prostate specific antigen, digital rectal examination and transrectal ultrasonography. J Urol 1994; 152: 1520–5.
10. Flanigan RC, Catalona WJ, Richie JP et al.: Accuracy of digital rectal examination and transrectal ultrasonography
in localizing prostate cancer. J Urol 1994; 152:1506–9.
11. Loch T, Leuschner I, Genberg C et al.: Improvement of transrectal ultrasound. Artificial neural network analysis
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12. Loch T, Eppelmann U, Lehmann J, Wullich B, Loch A, Stockle M: Transrectal ultrasound guided biopsy of the
prostate: random sextant versus biopsies of sono-morphologically suspicious lesions. World J Urol 2004; 22:
357–60.
13. Brawer MK, Chetner MP: Ultrasonography and biopsy of the prostate. In: Walsh PC, Retik A, Stamey TA, Vaughan
EJ, eds.: Campell´s Urology. Philadelphia: Saunders, 1997: 2506–18.
14. Raaijmakers R, Kirkels WJ, Roobol MJ, Wildhagen MF, Schroder FH: Complication rates and risk factors of 5802
transrectal ultrasound-guided sextant biopsies of the prostate within a population-based screening program.
Urology 2002; 60(5): 826–30.
15. Hoedemaeker RF, Rietbergen JB, Kranse R, Schroder FH, van der Kwast TH: Histopathological prostate cancer
characteristics at radical prostatectomy after population based screening. J Urol 2000; 164(2): 411–15.
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18. Price CP, Allard J, Davies G et al.: Pre- and post-analytical factors that may influence use of serum prostate
specific antigen and its isoforms in a screening programme for prostate cancer. Ann Clin Biochem 2001; 38
(Pt 3): 188–216.
19. Thompson IM, Goodman PJ, Tangen CM et al.: The influence of finasteride on the development of prostate cancer.
N Engl J Med 2003; 349: 215–24.
20. Carter HB, Epstein JI, Partin AW: Influence of age and prostate-specific antigen on the chance of curable prostate
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22. Bill-Axelson A, Holmberg L, Ruutu M, Haggman M, Andersson SO, Bratell S et al.: Radical prostatectomy versus
watchful waiting in early prostate cancer. N Engl J Med 2005; 352:1977–84.
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Corresponding author
Dr. med. Christof Börgermann
Klinik und Poliklinik für Urologie, Universitätsklinik Essen
Hufelandstr. 55, 45122 Essen, Germany
[email protected]
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Please answer the following questions to participate in our certified
Continuing Medical Education program. Only one answer is possible per question. Please select the answer that is most appropriate.
Question 1
Screening for the detection of prostate cancer is defined as
a)
b)
c)
d)
e)
Testing all men with the disease
Testing all healthy men
Testing asymptomatic men at risk for the disease
Testing symptomatic men at risk for the disease
Testing asymptomatic or symptomatic men at risk for the disease at their own request
Question 2
Approximately how many men die of prostate cancer in Germany every year?
a)
b)
c)
d)
e)
9,000
12,000
15,000
18,000
21,000
Question 3
A patient comes to your office and says his father died of prostate cancer. Screening is
recommended for this patient starting at what age?
a)
b)
c)
d)
e)
40
45
50
55
immediately on presentation, regardless of age
Question 4
What threshold value of PSA is now considered an indication for prostatic biopsy?
a)
b)
c)
d)
e)
2.5 ng/ml
3.0 ng/ml
3.5 ng/ml
4.0 ng/ml
4.5 ng/ml
Question 5
Which of the following is NOT a typical complication of an ultrasound-guided
transrectal sextant biopsy?
a)
b)
c)
d)
e)
urosepsis
prostatitis
hemospermia
hematuria
retrograde ejaculation
Question 6
What percentage of screened patients have a normal PSA level (i.e., < 4 ng/ml)?
a)
b)
c)
d)
e)
20%
40%
60%
80%
100%
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Question 7
What percentage of patients with a PSA level between 4 and 10 ng/ml will go on to have
a finding of prostate cancer on punch biopsy?
a)
b)
c)
d)
e)
0-10%
10-20%
20-30%
30-40%
40-50%
Question 8
A latent prostate cancer is found at autopsy in what percentage of men over age 70?
a)
b)
c)
d)
e)
up to 100%
up to 80%
up to 60%
up to 40%
up to 20%
Question 9
Which of the following imaging techniques is used in screening for prostate cancer?
a)
b)
c)
d)
e)
MRI
CT
Bone scan
PET-CT
None of the above
Question 10
Distant metastases are seen less commonly 10 years after diagnosis in patients who
were treated by radical prostatectomy than in patients who were merely observed. How
great is the difference between the prevalences of metastatic disease in these two
patient groups?
a)
b)
c)
d)
e)
10%
20%
30%
40%
50%
Important Information
This text is a
translation from
the original
German which
should be used
for referencing.
The German
version is
authoritative.
The Deutsches Ärzteblatt provides certified continuing medical education (CME) in accordance with
the requirements of the Chambers of Physicians of the German federal states (Länder). CME points
of the Chambers of Physicians can be acquired only through the Internet by the use of the German
version of the CME questionnaire within 6 weeks of publication of the article. See the following
website: www.aerzteblatt.de/cme.
The correct answers to this CME questionnaire will be published in Issue 45/2006 under this
heading.
The planned CME topic in Issue 41/2006 is "The diagnosis and treatment of neuropathic pain."
Dtsch Arztebl 2006; 103(37): A 2399–406 www.aerzteblatt.de
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