Prostate Cancer Detection in Older Men with and without Lower Urinary Tract Symptoms: A Population‐Based Study

This is the authors' abstract. We don't add key points for this paper.

To the Editor: Prostate cancer (PCa) and lower urinary tract symptoms (LUTS) are major health problems in aging men.1,2 Although it is not known whether patients benefit from early detection of PCa3 and no clear relationship between LUTS and PCa has been established,4,5 prostate specific antigen (PSA) testing is widely used for this purpose, especially in men with LUTS.1 The aim of this study was to determine the relationship between LUTS and PCa in community-dwelling older men. Prospectively collected data from a large population-based study (the Krimpen study) were analyzed.2 Men aged 50 to 78 without a radical prostatectomy, prostate or bladder cancer, or neurogenic bladder disease were invited. One thousand six hundred eighty-eight responders (50% of all eligible men) completed a self-administered questionnaire that included the International Prostate Symptom Score, which was used to rate LUTS severity: no (0), mild (1–7), moderate (8–19), and severe LUTS (>19). At a urology outpatient clinic, 1,661 men underwent digital rectal examination (DRE), PSA testing, and transrectal ultrasound of the prostate. All men provided written informed consent. The Medical Ethical Committee of the Erasmus Medical Center Rotterdam, the Netherlands, approved the study. Sextant prostate biopsies were taken from men with PSA values greater than 10 ng/mL, PSA values 2 ng/mL to 10 ng/mL if DRE or ultrasound was abnormal (i.e., suspect for carcinoma), or PSA values 1 ng/mL to 2 ng/mL if DRE was abnormal. Tumor grade and stage were determined in the biopsy specimen using Gleason score and TNM classification (T—the extent of the primary tumor; N—condition of the regional lymph nodes; M—the absence or presence of distant metastases). Lymph nodes or possible metastases were not analyzed in the current report. In the 171 performed biopsies (94% of those recommended according to the protocol), 57 carcinomas were found. The PCa detection rate increased with advancing age; in the age groups 50 to 54, 55 to 59, 60 to 64, 65 to 69, and 70 to 78, the detection rate was 1.8, 2.6, 2.8, 5.0, and 7.1, respectively (chi-square (χ2) linear trend, P < .001). Table 1 shows that the detection rate did not significantly differ according to LUTS severity (χ2 linear trend, P = .78; age stratification, P = .90). Forty-one men with a detected PCa (73%) had no or mild LUTS. Tumor stage and grade did not differ significantly between men aged 50 to 64 and those aged 65 to 78 or between LUTS severity groups (all comparisons χ2P> .56). Using a questionnaire validated for LUTS severity rating and a biopsy protocol independent from LUTS severity, the relationship between LUTS and PCa detection in a large population-based study was analyzed. Those results suggest that LUTS severity was not associated with the PCa detection rate. The fact that the majority of PCas develop in the peripheral zone of the prostate and need to be in advanced stage before provoking LUTS may explain this. Previous reports showed conflicting results, but their interpretation is difficult. In case-control studies, it was shown that men with PCa (cases) more often reported LUTS than those without PCa (controls),4 but the analyses of cases and controls in that study were not performed uniformly. This might have resulted in a substantially biased estimate, because men with LUTS are more often screened for PCa.1 Others have suggested a protective effect of LUTS,5 but it remains unclear how LUTS were analyzed in that study. Moreover, no pathophysiological explanation of the presumed protective effect can be given. Because of the lack of association between LUTS and PCa, performing a PSA test based on the presence of LUTS equals unselected screening. The value of such screening has yet to be established.3 We stress that, given present knowledge, LUTS severity should not be used as a criterion of whether to screen in daily practice. Instead, patient education should be directed at the lack of association between the presence of LUTS and the prevalence of PCa.