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Androgen deprivation therapy (ADT) for men with prostate cancer (PCa) results in accelerated bone loss and increased risk of bone fracture. The aim of the present study was to evaluate serum bone markers-sclerostin, Dickkopf-1 (DKK-1) and osteoprotegerin (OPG), in a cohort of 88 PCa patients without known bone metastases, managed with and without ADT, and to analyse their relationship with bone mineral density (BMD) and sex steroids. The cross-sectional analysis between acute-, chronic- and former-ADT groups and PCa controls showed that sclerostin and OPG levels significantly differed between them (p = 0.029 and p = 0.032). Groups contributing to these significant changes were recorded. There were no significant differences in serum DKK-1 levels across the four groups (p = 0.683). In the longitudinal analysis, significant % decreases within groups were seen for DKK-1 [chronic-ADT (- 10.06%, p = 0.0057), former-ADT (- 12.77%, p = 0.0239), and in PCa controls group (- 16.73, p = 0.0022); and OPG levels in chronic ADT (- 8.28%, p = 0.003) and PCa controls group (- 12.82%, p = 0.017)]. However, % changes in sclerostin, DKK-1, and OPG did not differ significantly over 6-months across the evaluated groups. Sclerostin levels showed significant positive correlations with BMD at baseline in the ADT group, while in PCa controls this correlation existed at both baseline and 6-month time points. Sclerostin correlated negatively with testosterone in former ADT users and in PCa controls. Possible prognostic features denoted by parallel increases in sclerostin and BMD are discussed., (© 2021. The Author(s).)

Māori experience poorer health statistics in terms of cancer incidence and mortality compared to non-Māori. For prostate cancer, Māori men are less likely than non-Māori men to be diagnosed with prostate cancer, but those that are diagnosed are much more likely to die of the disease than non-Māori men resulting in an excess mortality rate in Māori men compared with non-Māori. A review of the literature included a review of the epidemiology of prostate cancer; of screening; of access to healthcare and of treatment modalities. Our conclusion was that there are a number of reasons for the disparity in outcomes for Māori including differences in staging and characteristics at diagnosis; differences in screening and treatment offered to Māori men; and general barriers to healthcare that exist for Māori men in New Zealand. We conclude that there is a need for more culturally appropriate care to be available to Māori men., Competing Interests: Nil.

Background: Radical prostatectomy is the most common treatment for localised prostate cancer in New Zealand. Active surveillance was introduced to prevent overtreatment and reduce costs while preserving the option of radical prostatectomy. This study aims to evaluate the cost-effectiveness of active surveillance compared to watchful waiting and radical prostatectomy., Methods: Markov models were constructed to estimate the life-time cost-effectiveness of active surveillance compared to watchful waiting and radical prostatectomy for low risk localised prostate cancer patients aged 45-70 years, using national datasets in New Zealand and published studies including the SPCG-4 study. This study was from the perspective of the Ministry of Health in New Zealand., Results: Radical prostatectomy is less costly than active surveillance in men aged 45-55 years with low risk localised prostate cancer, but more costly for men aged 60-70 years. Scenario analyses demonstrated significant uncertainty as to the most cost-effective option in all age groups because of the unavailability of good quality of life data for men under active surveillance. Uncertainties around the likelihood of having radical prostatectomy when managed with active surveillance also affect the cost-effectiveness of active surveillance against radical prostatectomy., Conclusions: Active surveillance is less likely to be cost-effective compared to radical prostatectomy for younger men diagnosed with low risk localised prostate cancer. The cost-effectiveness of active surveillance compared to radical prostatectomy is critically dependent on the 'trigger' for radical prostatectomy and the quality of life in men on active surveillance. Research on the latter would be beneficial.

Purpose: To examine prostate-specific antigen (PSA) screening patterns and outcomes in rural and urban men in New Zealand., Methods: Men aged 40+ years were identified from 18 rural and 13 urban general practices across the Midland Cancer Network region. Computerized practice records were cross-referenced with community laboratory data to ascertain the number and level of PSA tests undertaken in 2010 and 3 years prior. For men with an elevated PSA result in 2010, practice records were searched for information on specialist visits, and they were cross-referenced with histology reports regarding biopsy and prostate cancer diagnosis., Findings: The study population included 34,960 men aged 40+ years, of whom 48% were enrolled in rural practices. Men in rural practices were 43% less likely to be screened with a PSA test in 2010, but they were 53% more likely to have an elevated PSA result. The prostate cancer detection rate from all screened men was 6 per 1,000 for rural men compared with 3 per 1,000 for urban men. Rural men were more likely diagnosed with Gleason score 9 tumors and metastatic disease., Conclusion: Significant differences were found in PSA screening patterns between rural and urban general practices. Due to lower screening rates, rural men were more likely to be diagnosed with prostate cancer when screened and also seemed to be diagnosed with more advanced disease compared with urban men. Despite ongoing discussions about the benefits and harms of PSA screening, PSA testing as such seems to be under-utilized in New Zealand rural practices., (© 2015 National Rural Health Association.)

This study aims to examine the survival disparity between Māori men and New Zealand (NZ) Europeans diagnosed with prostate cancer. We identified men aged 40+ years in the Midland Cancer Network region registered with prostate cancer in 2007-2010 in the Cancer Registry. Data were extracted from patient notes of all Māori men and a sample of NZ Europeans. The survival disparity between Māori men and Europeans was estimated by the Kaplan-Meier method and Cox proportional-hazards regression models after adjusting for other factors. This study included 535 men with prostate cancer (135 Māori men and 400 Europeans). The 5-year cancer-specific survival was 98.6% for men diagnosed with localised cancer, 88.8% for locally advanced disease and 19.1% for metastatic cancer. The all-cause survival and the cancer-specific survival were both significantly poorer for Māori men than for NZ Europeans (log rank test: P = 0.004, 0.006 respectively). The hazard ratio of cancer-specific survival for Māori men was 2.01 (95% CI: 1.21-3.36) compared with NZ Europeans. Māori men with prostate cancer had poorer all-cause survival and cancer-specific survival than NZ Europeans. Māori men were at risk of having more advanced disease at diagnosis, which explains most of the survival inequity between Māori men and NZ Europeans., (© 2016 John Wiley & Sons Ltd.)

Background: Androgen deprivation therapy (ADT) administered as a prostate cancer treatment is known to exert multiple side effects including bone deterioration leading to bone fracture. The current analysis is to evaluate the burden of fracture risk in the New Zealand prostate cancer (PCa) population treated with ADT, and to understand the subsequent risk of mortality after a fracture., Methods: Using datasets created through linking records from the New Zealand Cancer Registry, National Minimal Dataset, Pharmaceutical Collection and Mortality Collection, we studied 25,544 men (aged ≥40 years) diagnosed with PCa between 2004 and 2012. ADT was categorised into the following groups: gonadotropin-releasing hormone (GnRH) agonists, anti-androgens, combined androgen blockade (GnRH agonists plus anti-androgens), bilateral orchiectomy, and bilateral orchiectomy plus pharmacologic ADT (anti-androgens and/or GnRH agonists)., Results: Among patients receiving ADT, 10.8 % had a fracture compared to 3.2 % of those not receiving ADT (p < 0.0001). After controlling for age and ethnicity, the use of ADT was associated with a significantly increased risk of any fracture (OR = 2.83; 95 % CI 2.52-3.17) and of hip fracture requiring hospitalisation (OR = 1.82; 95 % CI 1.44-2.30). Those who received combined androgen blockade (OR = 3.48; 95 % CI 3.07-3.96) and bilateral orchiectomy with pharmacologic ADT (OR = 4.32; 95 % CI 3.34-5.58) had the greatest risk of fracture. The fracture risk following different types of ADT was confounded by pathologic fractures and spinal cord compression (SCC). ADT recipients with fractures had a 1.83-fold (95 % CI 1.68-1.99) higher mortality risk than those without a fracture. However, after the exclusion of pathologic fractures and SCC, there was no increased risk of mortality., Conclusions: ADT was significantly associated with an increased risk of any fracture and hip fracture requiring hospitalisation. The excess risk was partly driven by pathologic fractures and SCC which are associated with decreased survival in ADT users. Identification of those at higher risk of fracture and close monitoring of bone health while on ADT is an important factor to consider. This may require monitoring of bone density and bone marker profiles.

Introduction: Approximately 350 000 prostate-specific antigen (PSA) tests are undertaken in New Zealand on a quarter of a million men each year. A number of studies have looked at PSA testing done by general practitioners (GPs) and subsequent outcomes. Few have looked at the patient perspective after a raised PSA result., Aim: To explore patient experiences up to and following a raised PSA test., Methods: Thirty-one general practices within the Midland region were recruited. Community laboratory databases were used to identify all men with a first raised PSA test during 2010. Questionnaires were sent to these men., Results: One hundred and ninety-four (63%) eligible responses were received from 307 eligible men delivered questionnaires. For 54% of men this was their first PSA test. Most men (66%) identified that their PSA test was initiated by their GP. Forty-three percent of men identified having symptoms at the time of their first raised PSA test. A digital rectal examination (DRE) was performed on 73% of men at the time of the test. Fifty-eight percent of men were referred to see a specialist. Maori men were less likely to be referred after a raised PSA. Of all men referred, 61% received a biopsy., Discussion: PSA testing is predominantly initiated by GPs. We found the care pathway is variable for men after an elevated PSA result. Standardisation of the pathway prior to and post diagnosis would assist patients in knowing what to expect and would aid in GP management of men being investigated for prostate cancer.

Objectives: To examine diagnostic and treatment pathways for Māori (the indigenous people of New Zealand [NZ]) and NZ European men with prostate cancer in order to identify causes of higher mortality rates for Māori men., Methods: All Māori men (150) diagnosed with prostate cancer in the Midland Cancer Network region between 2007 and 2010 were identified from the NZ Cancer Registry and frequency age-matched with three randomly sampled NZ European men. Clinical records of these men were searched for information on clinical stage at diagnosis, comorbidities, and type of treatment for localised disease., Results: The final cohort included 136 Māori and 400 NZ European men, of whom 97 Māori and 311 NZ European were diagnosed with localised prostate cancer. Māori men were twice as likely to be diagnosed with distant metastases compared with NZ European men (19.1 vs 9.8 %). Māori men with localised disease were less likely to be treated with radical prostatectomy compared with NZ European men [RR 0.66 (95 % CI 0.48, 0.90)]. Multivariate regression analysis adjusted for age, D'Amico risk strata, comorbidities, and socioeconomic deprivation showed that Māori men were more likely to be managed expectantly [RR 1.74 (95 % CI 1.06, 2.57)]., Conclusion: Differences between Māori and NZ European men observed in the management of localised prostate cancer cannot be readily explained by patient characteristics, such as comorbidities or risk assessment at diagnosis. Poorer outcomes for Māori men may not only be related to later stage at diagnosis but differences in treatment modalities may also be a factor.

Objective: To examine temporal trends and current survival differences between Māori and non-Māori men with prostate cancer in New Zealand (NZ)., Patients and Methods: A cohort of 37,529 men aged ≥ 40 years diagnosed with prostate cancer between 1996 and 2010 was identified from the New Zealand Cancer Registry and followed until 25 May 2011. Cause of death was obtained from the Mortality Collection by data linkage. Survival for Māori compared with non-Māori men was estimated using the Kaplan-Meier method, and Cox proportional hazard regression models, adjusted for age, year of diagnosis, socioeconomic deprivation and rural/urban residence., Results: The probability of surviving was significantly lower for Māori compared with non-Māori men at 1, 5 and 10 years after diagnosis. Māori men were more likely to die from any cause [adjusted hazard ratio (aHR) 1.84, 95% confidence interval (CI) 1.72-1.97] and from prostate cancer (aHR 1.94, 95% CI 1.76- 2.14). The aHR of prostate cancer death for Māori men diagnosed with regional extent was 2.62-fold (95% CI 1.60-4.31) compared with non-Māori men. The survival gap between Māori and non-Māori men has not changed throughout the study period., Conclusion: Māori men had significantly poorer survival than non-Māori, particularly when diagnosed with regional prostate cancer. Despite improvements in survival for all men diagnosed after 2000, the survival gap between Māori and non-Māori men has not been reduced with time. Differences in prostate cancer detection and management, partly driven by higher socioeconomic deprivation in Māori men, were identified as the most likely contributors to ethnic survival disparities in NZ., (© 2014 The Authors. BJU International © 2014 BJU International.)

This review, based on published papers, aims to describe the costs of prostate cancer screening and to examine whether prostate cancer screening is cost effective. The estimated cost per cancer detected ranged from €1299 in The Netherlands to US$44,355 in the USA. The estimated cost per life-year saved ranged from US$3000 to US$729,000, while the cost per quality-adjusted life year (QALY) was AU$291,817 and Can$371,100. The most appropriate data for economic evaluation of prostate cancer screening should be the cost per QALY gained. The estimated costs per QALY gained by prostate cancer screening were significantly higher than the cost-effectiveness threshold, suggesting that even when based on favorable randomized controlled trials in younger age groups, prostate cancer screening is still not cost effective.

Objective: This study aims to (1) characterise men diagnosed with metastatic prostate cancer, (2) describe their management and (3) look at their survival., Methods: We identified patients registered with prostate cancer in the New Zealand Cancer Registry in the Midland Cancer Network region in 2009-2012 and examined these patients' clinical records to identify the metastatic cases. We investigated the patients' characteristics and the treatment pattern. All-cause survival was estimated by the Cox proportional hazards model., Results: Of the 2,127 men diagnosed with prostate cancer, 234 (26 Maori/Pacific and 208 non-Maori/non-Pacific) were diagnosed with metastatic prostate cancer. After the diagnosis, 194 (82.9%) patients received androgen deprivation therapy (ADT), 5 had chemotherapy and 104 (44.4%) had radiotherapy. Of the patients treated with ADT, 46 (23.7%) had no monitoring prostate-specific antigen tests. Fifty-nine percent of the patients were alive after 12 months and 35% after 24 months. The hazard ratio for the Maori/Pacific men was 1.49., Conclusion: Overall, the survival of patients with metastatic prostate cancer was poor. There seems to be a strong case for the development of New Zealand guidelines on the management of metastatic disease including the use of first-line treatments, the ongoing monitoring for the development of castration-resistant prostate cancer (CRPC) and the treatment of CRPC., (© 2014 S. Karger AG, Basel.)

Background: Māori men in New Zealand have higher mortality from prostate cancer, despite having lower incidence rates. The objective of this study was to examine patterns of screening for prostate cancer in primary care and follow-up investigations after an elevated prostate-specific antigen (PSA) result in Māori and non-Māori men in order to help explain the observed differences in incidence and mortality., Methods: Men aged 40+ years were identified from 31 general practices across the Midland Cancer Network region. Computerised practice records were cross-referenced with laboratory data to determine the number and value of PSA tests undertaken between January 2007 and December 2010. Screening rates were calculated for the year 2010 by age, ethnicity, and practice. For men with an elevated PSA result information on specialist referrals and biopsy was extracted from practice records. Practice characteristics were assessed with respect to screening rates for Māori and non-Māori men., Results: The final study population included 34,960 men aged 40+ years; 14% were Māori. Māori men were less likely to be screened in 2010 compared with non-Māori men (Mantel Haenszel (M-H) age-adjusted risk ratio (RR), 0.52 [95% CI, 0.48, 0.56]). When screened, Māori men were more than twice as likely to have an elevated PSA result compared with non-Māori men (M-H age-adjusted RR, 2.16 [95% CI, 1.42, 3.31]). There were no significant differences between Māori and non-Māori men in the rate of follow-up investigations and cancer detection. Māori provider practices showed equal screening rates for Māori and non-Māori men, but they were also the practices with the lowest overall screening rates., Conclusions: Māori men were half as likely to be screened compared to non-Māori men. This probably explains the lower reported incidence of prostate cancer for Māori men. Practice characteristics had a major influence on screening rates. Large variation in screening behaviour among practices and differences in follow-up investigations for men with an elevated PSA result seems to reflect the uncertainty among GPs regarding PSA screening and management.

Background: Screening for prostate cancer (PCa) using the prostate-specific antigen (PSA) test is widespread in New Zealand. Aim. This study estimates the costs of identifying a new case of PCa by screening asymptomatic men., Methods: Men aged 40+, who had PSA tests in 31 general practices in the Midland Cancer Network region during 2010, were identified. Asymptomatic men without a history of PCa were eligible for this study. A decision tree was constructed to estimate the screening costs. We assumed GPs spent 3 minutes of the initial consultation on informed consent of PCa screening., Results: About 70.7% of the estimated costs were incurred in general practice. The screening costs per cancer detected were NZ$10 777 (€5820; £4817). The estimated costs for men aged 60-69 were NZ$6268 compared to NZ$24 290 for men aged 40-49, NZ$30 022 for 50-59 and NZ$10 957 for those aged 70+. The costs for Māori were NZ$7685 compared to NZ$11 272 for non-Māori. The costs for men without PSA testing history in 2007-09 were NZ$8887 compared to NZ$13 870 if the men had PSA tests in 2007-09. If we assumed a PSA test involved a full 15-minute general practice consultation, the estimated costs increased to NZ$26 877 per PCa identified., Conclusions: Screening of asymptomatic men for PCa is widely practiced. Most of the costs of screening were incurred in general practice. Calls for men to receive increased information on the harms and benefits of screening will substantially increase the costs. The current costs could be reduced by better targeting of screening.

Introduction: Prostate cancer is a common health problem in men worldwide. This systematic review has been undertaken to determine if there are differences in incidence of and mortality from prostate cancer between rural and urban men. The understanding of geographical patterns of prostate cancer incidence and mortality is necessary in order to identify and assess any disparities between rural and urban residents in gaining access to healthcare services, such as screening, diagnosis and treatment., Methods: Medline, CINAHL and Embase were searched using relevant mesh phrases, such as 'prostate cancer incidence rural' or 'prostatic neoplasms mortality rural'. Secondary literature and reports not published in peer-reviewed journals were included if inclusion criteria had been met. The following inclusion criteria were applied: cohort (population-based study) of adult men, diagnosis of prostate cancer, comparing rural and urban groups, and incidence or mortality with available statistical parameters as outcome., Results: In total, 25 studies were found to fit the inclusion criteria. Sixteen cohort studies were identified that examined incidence of prostate cancer in rural and urban populations, while 18 studies focused on mortality. Nine of these publications discussed both aspects. Twenty of these studies were published in scientific journals, while five were reports identified through secondary literature search. Prostate cancer incidence was found to be higher in urban men, while mortality patterns seemed to vary to some degree depending on different definitions of rural/urban groups, as well as on variations in demographic factors and study periods. There is evidence, however, that after prostate-specific antigen testing was introduced death rates tended to be higher in rural men with prostate cancer., Conclusions: The review of the literature showed that in spite of inconsistent definitions of rural/urban categories among studies the majority reported higher incidence rates in urban men. This finding suggests that rural men are less likely to be screened and less likely to be subsequently diagnosed with prostate cancer. Although mortality patterns tended to be heterogeneous, there was some evidence that rural residents with prostate cancer experience higher death rates. It would be beneficial if future studies take into consideration factors such as stage at initial diagnosis, ethnicity, and socioeconomic and health status when assessing differences in cancer outcomes. Few studies in this review accounted for one or more of these variables, although there are indications that they contribute to differences in prostate cancer incidence and mortality between rural and urban populations.