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The current TNM staging system classifies prostate tumors with abnormal transrectal ultrasound but normal digital rectal examination as clinical stage T2. However, most urologists consider these tumors as clinical stage T1c due to the perceived inaccuracy of transrectal ultrasound in clinical staging. To determine the role of transrectal ultrasound in the clinical staging of prostate cancer we evaluated the pathological stage and disease-free survival of patients undergoing radical prostatectomy who had tumor detected by needle biopsy because of elevated serum prostate specific antigen with or without transrectal ultrasound abnormalities.

Will early detection impact on stage of disease and recurrence of prostate cancer in a high risk population? We initiated a community based study to educate and recruit African American men for early diagnosis of prostate cancer, that is the Detroit Education and Early Detection (DEED) study. Our objective was to evaluate our recruitment process for this target population, examine the percentage of organ confined prostate cancer in men undergoing radical prostatectomy and measure recurrence biochemically.

Our recent cost analysis of prostate cancer early detection evaluated the economic performance of various prostate specific antigen (PSA) screening approaches, detected marginal cost variations with time and used a benefit-cost calculation as a framework for further discussion. Receiver operator characteristic analysis initially suggested an optimal test performance for PSA of 2 to 3 ng./ml. when used alone and at approximately 3 ng./ml. in combination with digital rectal examination. However, lower PSA decision levels require cost justifications. Marginal cost analysis demonstrated markedly decreased use of digital rectal examination by year 3 due to significantly lower sensitivity for incident cancer. The benefit-cost equation acknowledges that many parameters of cost and probability are not definitive to date yet illustrated major points for discussion. The cost parameters most sensitive to incremental change in decreasing order are the specificity of the screening test, benefits obtained from early therapy and prevalence of the disease. Discussions about improving the likelihood of overall benefit for the United States population should focus on these parameters, as well as social and ethical implications.

The American Cancer Society-National Prostate Cancer Detection Project is a prospective, comparative study of a cohort of 2,999 men 55 to 70 years old not suspected on entry of having prostate cancer. A total of 164 prostate cancers is available from this project for analysis. A small proportion of tumors detected were advanced in terms of the clinical stage at diagnosis. Cancer detected by digital rectal examination tended to be more advanced than that found on the basis of only transrectal ultrasound or prostate specific antigen (PSA). A large proportion of patients received curative therapy involving radical prostatectomy in 67.1% and radiotherapy in 18.3%. Of 103 men presumed to have organ confined disease and treated by prostatectomy 64 (37.9%) actually had locally extensive cancer pathologically. PSA level and PSA density were associated with the detection of organ confined cancer but several advanced tumors had PSA levels in the normal range. Age referenced PSA, compared to conventional standards, demonstrated lower sensitivity to cancer with little improvement in specificity. The disease resulting from this multimodality detection effort represented a spectrum of pathological conditions. Further followup and evaluation are needed to determine whether these benefits are reflected in long-term mortality and survival experience.

Transrectal ultrasound (TRUS) guided systematic biopsy of the prostate is the gold standard diagnostic modality for prostate cancer. Consequently, the value of discrete hypoechoic lesions on TRUS lesions considered suspicious for cancer deserves meticulous reevaluation, specifically in the prostate specific antigen era when the majority of tumors diagnosed are nonpalpable. We studied whether the predictability of a biopsy core changes if the tissue comes from an isoechoic vs hypoechoic lesion.