Prostate-Cancer Screening Guidelines

The rationale for screening is that early detection and treatment of asymptomatic cancers could extend life, as compared with treatment at the time of clinical diagnosis. The introduction of prostate-specific antigen (PSA) testing has nearly doubled the lifetime risk of receiving a diagnosis of prostate cancer.

Prostate-Cancer Screening Guidelines.

Recommendation	American Urological Association	American Cancer Society
Shared decision making between patient and clinician	Yes	Yes (consider use of decision aid)
Age to begin offering screening? (yr) *Average-risk patients *High-risk patients (black patients and those with first-degree relative with prostate cancer)	40 40	50 40-45
Discontinuation of screening	Life expectancy <10 yr	Life expectancy <10 yr
Screening tests	PSA, digital rectal examination	PSA, optional digital rectal examination
Frequency of screening	Annual (possibly less often for men in their 40s)†	Annual (every other year when PSA <2.5 ng/ml)
Criteria for biopsy referral	Age, family history, race or ethnic group, findings on digital rectal examination, total PSA, free PSA, PSA velocity, PSA density, previous biopsy findings, coexisting conditions	PSA >/=4.0 ng/ml, abnormal digital rectal examination; individualized risk assessment if PSA is 2.5–4.0 ng/ml

† The guidelines indicate that the initial PSA value at 40 years of age (relative to the median value of 0.6 to 0.7 ng per milliliter for this age group) would determine subsequent (but unspecified) screening intervals. The National Comprehensive Cancer Network recommends using a PSA cutoff level to determine whether subsequent testing should be performed annually or at 45 years of age (and then at 50 years of age). However, these recommendations are not evidence-based.


References:

1. Hoffman RM. Screening for Prostate Cancer. N Engl J Med. 2011 Oct 26. [Medline]
2. Wolf AM, Wender RC, Etzioni RB, Thompson IM, D'Amico AV, Volk RJ, Brooks DD, Dash C, Guessous I, Andrews K, DeSantis C, Smith RA; American Cancer Society Prostate Cancer Advisory Committee. American Cancer Society guideline for the early detection of prostate cancer: update 2010. CA Cancer J Clin 2010;60:70-98. [Medline]
3. Greene KL, Albertsen PC, Babaian RJ, Carter HB, Gann PH, Han M, Kuban DA, Sartor AO, Stanford JL, Zietman A, Carroll P. Prostate specific antigen best practice statement: 2009 update. J Urol 2009;182:2232-41. [Medline]

Tumor, Node, Metastasis International Staging System for Lung Cancer

Stage	TNM Descriptors	5-Year Survival Rate, %
		Clinical Stage	Surgical-Pathologic Stage
IA IB IIA IIB IIB IIIA IIIB IV	T1 N0 M0 T2 N0 M0 T1 N1 M0 T2 N1 M0 T3 N0 M0 T3 N1 M0 T1–2–3 N2 M0 T4 N0–1–2 M0 T1–2–3–4 N3 M0 Any T any N M1	61 38 34 24 22 9 13 7 3 1	67 57 55 39 38 25 23 <5 <3 <1

TUMOR (T) STATUS

• T0 No evidence of a primary tumor
• TX Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy
• TIS Carcinoma in situ
• T1 Tumor <3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than lobar bronchus (i.e., not in main bronchus)
• T2 Tumor with any of following: >3 cm in greatest dimension; involves main bronchus, >2 cm distal to the carina; invades visceral pleura; associated with atelectasis or obstructive pneumonitis extending to hilum but does not involve entire lung
• T3 Tumor of any size that directly invades any of the following: chest wall (including superior sulcus tumors), diaphragm, mediastinal pleura, parietal pericardium; or tumor in main bronchus <2 cm distal to carina but without involvement of carina; or associated atelectasis or obstructive pneumonitis of entire lung
• T4 Tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, esophagus, vertebral body, carina; or tumor with a malignant pleural or pericardial effusion^a, or with satellite tumor nodule(s) within the ipsilateral primary-tumor lobe of the lung.

LYMPH NODE (N) INVOLVEMENT

• NX Regional lymph nodes cannot be assessed
• N0 No regional lymph node metastasis
• N1 Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes, and intrapulmonary nodes involved by direct extension of the primary tumor
• N2 Metastasis to ipsilateral mediastinal and/or subcarinal lymph nodes(s)
• N3 Metastasis to contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)

DISTANT METASTASIS (M)

• MX Presence of distant metastasis cannot be assessed
• M0 No distant metastasis
• M1 Distant metastasis present^b

^a Most pleural effusions associated with lung cancer are due to tumor. However, in a few patients with multiple negative cytopathologic exams of a non-bloody, non-exudative pleural or pericardial effusion that clinical judgment dictates is not related to the tumor, the effusion should be excluded as a staging element and the patient’s disease staged as T1, T2, or T3.

^b Separate metastatic pulmonary tumor nodule(s) in the ipsilateral nonprimary tumor lobe(s) of the lung are classified as M1.

References:

1. Mountain CF. Revisions in the International System for Staging Lung Cancer. Chest. 1997 Jun;111(6):1710-7.[Medline]

Guidelines for the Use of Erythropoietic Proteins in Anaemic Patients with Cancer

Anaemia is a frequent finding in cancer patients and should be carefully assessed. Additional causes of anaemia such as iron deficiency, bleeding, nutritional defects or haemolysis should be corrected prior to erythropoietic protein therapy. The following recommendations are related to adult cancer patients with solid tumours or haematological malignancies:

• In cancer patients receiving chemotherapy and/or radiotherapy, treatment with erythropoietic proteins should be initiated at a Hb level of 90–110 g/L based on anaemia-related symptoms.
• In patients with cancer-related anaemia not undergoing chemotherapy and/or radiotherapy, treatment with erythropoietic proteins should be initiated at a Hb level of 90–110 g/L based on anaemia-related symptoms.
• Erythropoietic proteins may be considered in asymptomatic, anaemic patients with a Hb level of 90–110 g/L to prevent a further decline in Hb, according to individual factors (e.g., type/intensity of chemotherapy, baseline Hb).
• For anaemic patients who are transfusion-dependent, erythropoietic proteins should be initiated in addition to RBC transfusions.
• We do not recommend the prophylactic use of erythropoietic proteins to prevent anaemia in patients undergoing chemotherapy and/or radiotherapy who have normal Hb values at the start of treatment.
• Elderly patients experience the same benefits from treatment with erythropoietic proteins as younger patients.
• The target Hb concentration should be 120–130 g/L.
• The two major goals of erythropoietic protein therapy should be to improve quality-of-life (QOL) and prevent transfusions.
• The use of erythropoietic proteins with the aim of improving survival or response to treatment is not recommended as there is no evidence to support this. Further studies are needed.
• Within reasonable limits of body weight, fixed doses of erythropoietic proteins should be used.
• We recommend the dosing of erythropoietic proteins according to Fig. 1. However, the decision to dose-escalate cannot be generally recommended and must be individualised. Treatment should be continued as long as Hb levels remain </=120–130 g/L and patients show symptomatic improvement. For patients reaching the target Hb, individualised titration of lowest effective maintenance dose should be made repeatedly.
• Despite the common use of epoetin alfa QW (40,000 IU), there is limited evidence to support this dosing schedule. The QW application of epoetin beta (30,000 IU) has been shown to be effective in patients with non-myeloid haematological malignancies. The QW administration of darbepoetin alfa (2.25 µg/kg) can be recommended. There is currently limited evidence to support the use of darbepoetin alfa in Q2W, Q3W or Q4W dosing intervals.
• The use of higher initial doses of erythropoietic proteins can currently not be recommended as a standard approach with epoetin alfa or epoetin beta, but limited evidence exists for darbepoetin alfa. Further studies are needed.
• There are no predictive factors of response to erythropoietic proteins that can be routinely used in clinical practice; a low serum erythropoietin (EPO) level (in particular in haematological malignancies) is the only verified predictive factor of some importance. Values must be interpreted relative to the degree of anaemia present.
• For patients undergoing autologous blood stem cell transplants, the effects of erythropoietic proteins have not yet been convincingly shown and they cannot therefore be recommended.
• For patients undergoing allogeneic blood stem cell transplants, the clinical impact of erythropoietic proteins is limited and they can only be recommended on an individual basis.
• The fear of pure red cell aplasia (PRCA) should not lead to erythropoietic proteins being withheld in patients with cancer.
• When using erythropoietic proteins to treat anaemia in cancer patients, the combined analysis of all study data indicates a slightly increased risk of thromboembolic events. However, this may be related to the target Hb level achieved.

Fig. 1

Abbreviations: Hb, haemoglobin; RBC, red blood cells; QOL, quality of life; TIW, three times per week; PRCA, pure red cell aplasia; QW, once per week; Q2W, once every 2 weeks; Q3W, once every 3 weeks.

References:

1. Bokemeyer C, Aapro MS, Courdi A, Foubert J, Link H, Osterborg A, Repetto L, Soubeyran P; European Organisation for Research and Treatment of Cancer (EORTC) Taskforce for the Elderly. EORTC guidelines for the use of erythropoietic proteins in anaemic patients with cancer: 2006 update. Eur J Cancer. 2007 Jan;43(2):258-70. [Medline]
2. Henry DH. Guidelines and recommendations for the management of anaemia in patients with lymphoid malignancies. Drugs. 2007;67(2):175-94. [Medline]