Fall 2012 - 08.pdf 667Vol. 9 | No. 4 | Fall 2012 |U R O LO G Y J O U R N A L Prostate Cancer Predicting Factors A Preliminary Report from Tehran Gholamreza Pourmand,1 Farzad Allameh,1 Kazem Mohammad,2 Sanaz Dehghani,1 Bita Pourmand,3 Abdolrasoul Mehrsai,1 Seyed Hamed Hosseini1 Purpose: To determine the probability of having prostate cancer (PCa) using the combination Materials and Methods: A total of 160 patients and 190 controls were enrolled in this hos- pital-based case-control study. Using a logistic regression model and the odds ratio of age and PSA level, the probability of PCa was estimated based on serum level of PSA and age of the participants. Results: The mean age of patients with PCa and benign prostatic hyperplasia (BPH) was 67.75 ± 8.81 and 62.07 ± 8.71 years, respectively (P < .000). Using univariate analysis, we found that increase in life decades of the cases almost doubles the risk of having PCa (odds ratio = 1.95; P = .00), and the probability of developing cancer may increase by 74% in ketchup consumers. After multiple variable regressions, it was revealed that the odds of developing PCa increase PCa. Conclusion: In clinical practice, PSA level combined with the age at presentation can be used as predictors of PCa probability and the necessity of biopsy. Keywords: - Corresponding Author: Sanaz Dehghani, MD Urology Research Center, Sina Hospital, Imam Khomeini St., Hassan Abad Square, Tehran, Iran Tel: +98 21 6634 8560 Fax: +9821 6634 8561 E-mail: sanaz_dehgha- ni2002@yahoo.com Received August 2011 Accepted January 2012 1Urology Research Center, Sina Hospital, Tehran Uni- versity of Medical Sciences, Tehran, Iran 2Epidemiology & Biostatistics Department, Tehran University of Medical Sciences, Tehran, Iran 3Research Development Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran UROLOGICAL ONCOLOGY 668 | INTRODUCTION P rostate cancer (PCa) is the third most commonly di- agnosed cancer in many countries and the second cause of cancer death among men.(1) In Iran, PCa is reportedly the 3rd most commonly diagnosed visceral can- cer, accounting for almost 7.75% of new cancer cases, and is the 7th most common cause of cancer death.(2) The overall detection rate of PCa in Iran is 3.5%.(3,4) According to the Ministry of Health Cancer Registry report in 2004 and 2005 to 2006, the age-standardized rate of inci- dence of PCa in Iran are respectively 7.24 and 9.22 men per 100 000.(5,6) This rate is apparently less than the rate reported for Western countries, especially for the US (49.4 per 100 000 and 158.2 per 100 000, respectively), but it is still con- siderable in comparison to the rate in Eastern Asian countries (1.6 per 100 000).(3) Among various important determinants of PCa develop- ment,(4) age are considered to be the most important factors. The annual PCa screening is rootinely performed using serum screening for assessing tumor control and its impact on pros- (7) A serum PSA level of 4 ng/mL is usually considered the cutoff threshold, above which further evaluations (prostate biopsy) are required. But recently, there have been many which PSA levels are below 10 ng/mL and in the range of 4 to 10 ng/mL. It is evident that in epidemiologic studies, sometimes diag- noses are made higher or lower in frequency compared to the real-life situation in the society. In case of PCa, under- diagnosis of the disease is rather common.(8,9) Accepting a lower threshold for higher detection rate of PCa will result in many unnecessary biopsies and their complications, such as bleeding, hematuria, urinary tract infection, and sepsis.(10) As Schroder and colleagues have discussed, no single thresh- (4) To increase the predictive value for PSA and improve its positive predictive value in screening tests, several methods have evolved recently for earlier detection of PCa and avoid- time (PSADT), PSA velocity, percent free PSA, and age-spe- Regarding the above-mentioned facts, an individual with an elevated level of PSA may ask his urologist about the prob- ability of having cancer. The primary study objective was to help urologists decide whether or not a patient needs a tran- srectal ultrasonography (TRUS)-guided biopsy to rule out PCa. In the current study, we provided a model analyzed by the logistic regression to predict the risk of PCa based on age and the serum PSA level in Iranian population. MATERIALS AND METHODS The study population comprised patients referred to our clin- ic for TRUS-guided biopsy from April 2009 to September 2009. The study protocol was approved by Medical Ethics Committee of Tehran University of Medical Sciences. guided biopsy served as the case group and individuals with any pathologic diagnosis other than PCa as controls. Accord- ingly, 160 patients were included in the case group and 190 patients entered the control group. Both groups had same so- cio-economic status. The same urologist performed 12-core TRUS-guided biopsy for all the patients. Using an unconditional logistic regression model and the odds ratio (OR) regarding PSA and age, the probability of PCa was estimated based on age at presentation and serum PSA level. The results are presented as mean ± standard de- viation. In univariate analysis, OR was calculated for evalu- ating the strength of association. The appropriate variables Hosmer-Lemeshow test. The accuracy of the diagnostic tests was studied by receiver operating characteristic (ROC) curve considered at P < .05. RESULTS The mean age of patients with and without PCa was 67.75 ± 8.81 and 62.07 ± 8.71 years, respectively (P < .00). Other demographic and clinical characteristics are presented in Ta- Urological Oncology 669Vol. 9 | No. 4 | Fall 2012 |U R O LO G Y J O U R N A L Prostate Cancer Predicting Factors | Pourmand et al ble 1. The increase in life decades of the cases almost doubled the risk of developing PCa (OR = 1.95; P < .00). Furthermore, the probability of developing PCa reached 74% in ketchup - cept red meat that showed a protective effect against devel- oping PCa; OR = 0.75; P relationship with developing PCa (Table 1). Age was the only PCa predicting variable that remained un- changed after multivariate logistic regression analysis. We found that the probability of developing PCa increased by 90% for every decade after adjustment (OR adj = 1.90; P < .00). between free, total, and free/total PSA in both groups. The difference between patients with PCa and BPH is presented in Figures 1 to 3 according to various age groups. In addition, using free/total PSA provided a more precise means of differ- entiating patients with BPH (Table 3 and Figure 4). DISCUSSION Findings of the present study showed that the probability of developing PCa almost doubles for every life decade. Fur- other risk factors, including ketchup, red meat, garlic, and fatty diet, and developing PCa. The rate of cancer detection varies in different countries with regard to PSA level. A study on 297 male US residents with either high PSA or abnormal DRE reported the PCa detec- tion rate of 44% following prostate biopsy.(9,11) However, the data are not compatible with the studies performed in simi- lar countries. The study accomplished by Catalona and col- leagues reported the cancer detection rate of about 4.6%.(12) With a cutoff level of 2 ng/mL for serum total PSA, the detec- tion rate is 3.8% in Iran.(4) Table 1. Basic characteristics of patients in PCa and BPH groups.* Variables PCa BPH Odds ratio crude (P) Age, y ≤ 50 50 to 59 60 to 69 ≥ 70 6 (1.6%) 80 (21.4%) 135 (36.1%) 153 (40.9%) 16 (8.4%) 70 (36.8%) 69 (36.3%) 35 (18.4%) 1.95 ( .00) Marriage 157 (98.1%) 188 (98.9%) 0.56 ( .52) Family history 23(14.4%) 19 (10%) 1.51 ( .21) Vasectomy 4 (2.1%) 1 (0.6%) 0.29 ( .27) Smoking 27 (16.9%) 44 (23.2%) 0.67 ( .15) Diabetes mellitus 12 (7.5%) 17 (8.9%) 0.83 ( .63) Garlic consumption Never Low Moderate High 35 (21.9%) 78 (48.8%) 31 (19.4%) 16 (10%) 43 (22.6%) 94 (49.5%) 37 (19.5%) 16 (18.4%) 1.05 ( .68) Ketchup consumption Low Moderate High 36 (22.9%) 77 (48.1%) 72 (29.4%) 70 (36.8%) 90 (47.4%) 30 (15.8%) 1.74 ( .00) Red meat consumption Low Moderate High 69 (43.1%) 68 (42.5%) 23 (14.4%) 59 (31.4%) 99 (52.7%) 30 (16.0%) 0.75 ( .07) Fatty diet Low Moderate High 123 (76.9%) 23 (14.4%) 14 (8.8%) 132 (69.8%) 43 (22.8%) 14 (7.4%) 0.86 ( .40) *PCa indicates prostate cancer; and BPH, benign prostatic hyperplasia. 670 | need for regional models to estimate the pretest probability of PSA in different parts of the world. Prostate Cancer Prediction Trial (PCPT), conducted by Na- tional Cancer Institute, was a seven-year study of US men with PSA < 3 ng/mL and normal DRE. Several risk factors, such as race, DRE, family history, annual biopsies, and age, were considered along with PSA level. This study evaluated the risk of cancer detection in US low-risk population.(13) The European Randomized Study of Screening for Prostate Cancer (ERSPC) was also performed to develop a statisti- cal model for PCa prediction in the European population. In this study, the prostate volume was added to assess factors in PCPT study in order to enhance the accuracy of PCa risk assessment model.(8) In our study, the factors, including ketchup, red meat, garlic, and fatty diet, were also studied. Some studies have shown Urological Oncology Table 2. Comparing lab criteria in PCa and BPH groups.* PCa BPH Mean difference (95% confidence interval) Total PSA, ng/mL 28.04 ± 60.82 6.08 ± 5.99 -21.95 (-28.19 to -15.71) Free PSA, ng/mL 2.97 ± 9.32 1.30 ± 1.59 -1.67 (-2.77 to -0.57) Total/Free PSA 11.63 ± 6.40 19.60 ± 18.01 7.97 (4.52 to 11.42) Prostate volume, mL 48.84 ± 25.21 57.49 ± 35.91 8.65 (2.81 to 14.48) *PCa indicates prostate cancer; BPH, benign prostatic hyperplasia; and PSA, prostate-specific antigen. Figure 3. Mean (95% confidence interval) serum level of free PSA in different age groups of patients with prostate cancer and benign prostatic hyperplasia. Figure 1. Mean (95% confidence interval) serum level of free/ total PSA in different age groups of patients with prostate cancer and benign prostatic hyperplasia. Figure 2. Mean (95% confidence interval) of total PSA in different age groups of patients with prostate cancer and benign prostatic hyperplasia. 671Vol. 9 | No. 4 | Fall 2012 |U R O LO G Y J O U R N A L a relationship between the aforementioned risk factors and relationship was found between age and PCa. The predictive value of PSA test increases with age.(14) Stud- ies show that positive predictive value for PSA > 4 ng/mL is about 5.6% and the cancer detection rate by simple PSA test is 4.6%. These odds differ when PSA values are interpreted with regard to the age of patients. The rate of cancer detec- tion in people aged between 40 and 49 years is 1.4% while it is 1.6% in 50 to 59 years. This rate is over 4.9% in 60 to 69 years and reaches 12.9% for men older than 70 years.(15) As a result, age was included in our analytic model as an im- portant determinant for the risk of PCa. Our results cannot be generalized to other counties and populations. CONCLUSION Considering the obtained results, it seems that age of the pa- tients as well as free/total PSA results are the best predicting factors of PCa in hospital-based urology clinic patients. ACKNOWLEDGEMENTS This study was supported by grants from Tehran University of Medical Sciences Research Fund. We would like to thank Ms Heidari for her cooperation and assistance as well as the patients who participated in this study. CONFLICT OF INTEREST None declared. Table 3. lab tests accuracy in diagnosing patients with PCa and BPH. * Area under curve 95% confidence interval P Total PSA, ng/mL 0.798 0.757 to 0.839 .000 Free PSA, ng/mL 0.623 0.570 to 0.675 .000 Total/Free PSA 0.817 0.776 to 0.858 .000 *PCa indicates prostate cancer; BPH, benign prostatic hyperpla- sia; and PSA prostate-specific antigen. Figure 4. Receiver operating characteristic curve, comparing total PSA, free PSA, free/total PSA sensitivity and specificity. REFERENCES 1. 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