What the U.S. Preventive Services Task Force Missed in Its Prostate Cancer Screening Recommendation

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "What the U.S. Preventive Services Task Force Missed in Its Prostate Cancer Screening Recommendation"

Transcription

1 In the Balance M open early What the USPSTF Missed in Its Prostate Cancer Screening Recommendation What the U.S. Preventive Services Task Force Missed in Its Prostate Cancer Screening Recommendation William J. Catalona, MD; Anthony V. D Amico, MD; William F. Fitzgibbons, MD; Omofolasade Kosoko-Lasaki, MD; Stephen W. Leslie, MD; Henry T. Lynch, MD; Judd W. Moul, MD; Marc S. Rendell, MD; and Patrick C. Walsh, MD This article was published at on 22 May The U.S. Preventive Services Task Force (USPSTF), a panel that does not include urologists or cancer specialists, has just recommended against prostate-specific antigen (PSA)-based screening for prostate cancer, stating that screening may benefit a small number of men but will result in harm to many others (1). Recognizing that prostate cancer remains the second-leading cause of cancer deaths in men, we, an ad hoc group that includes nationally recognized experts in the surgical and radiological treatment of prostate cancer, oncologists, preventive medicine specialists, and primary care physicians, believe that the USPSTF has underestimated the benefits and overestimated the harms of prostate cancer screening. Therefore, we disagree with the USPSTF s recommendation. The USPTSF bases its recommendation, in large part, on the 2 largest published randomized clinical trials (2). The U.S. PLCO (Prostate, Lung, Colorectal, and Ovarian) Cancer Screening Trial randomly assigned 76#685 men ages 55 to 74 years to receive either annual screening for 6 years or usual care (3). By 2009, 57% of the men had been followed for at least 13 years. The cumulative incidence rate for prostate cancer was slightly higher in the screened group, and prostate cancer mortality did not differ significantly between groups (3). The ERSPC (European Randomized Study of Screening for Prostate Cancer) randomly assigned 162#243 men aged 55 to 69 years to either PSA screening once every 4 years or to an unscreened control group (4). After a median of 11 years of follow-up, the cumulative incidence of prostate cancer was 8.2% in the screened group and 4.8% in the control group. Prostate cancer death was reduced by 21% in the screened compared with the control group and 29% after adjustment for noncompliance (5). The Task Force concluded

2 that this decrease in prostate cancer specific mortality amounted to few lives saved and did not outweigh the harms of screening and diagnosis (false-positive results and associated anxiety and biopsy complications) and the harms related to the treatment of screendetected cancer. The Task Force s evidence review (2) did acknowledge strong evidence that treatment of localized prostate cancer reduced mortality compared with observation alone, citing a Scandinavian randomized, controlled trial with 15 years of follow-up showing that radical prostatectomy resulted in a sustained 38% decrease in prostate cancer specific mortality (15% vs. 21%; risk ratio, 0.62 [95% CI, 0.44 to 0.87]) and 25% reduction in all-cause mortality (risk ratio, 0.75 [CI, 0.61 to 0.92]) (6). It also acknowledged other trials of surgery and radiation therapy showing an approximate 35% decrease in mortality. However, the Task Force s view was that perioperative events, urinary incontinence, and erectile dysfunction as complications of prostatectomy and bowel problems associated with radiation therapy must be considered, in addition to the mortality benefits of treatment. In formulating its recommendation, we believe that the USPSTF either overlooked or misinterpreted the effect of significant methodological flaws in the 2 major clinical trials of screening. The most important flaws of the PLCO are the greater than 50% contamination rate by nonprotocol PSA measurements in the control group, prescreening of 40% of study participants before enrollment in the trial, and the fact that two thirds of patients with abnormal screening tests did not have prompt biopsy (7). These issues, in our opinion, impair the claim that the PLCO is a true screening trial. In the ERSPC, compared with the PLCO, participants were younger, the PSA cutoff was lower, there was only approximately 15% contamination, and prompt biopsy was done far more frequently after positive PSA values. A secondary analysis of data from the Rotterdam site of the ERSPC that corrected for failure of participants to have protocol-prescribed screening procedures as well as contamination showed that PSA screening reduced the risk for dying of prostate cancer by as much as 31% (8). A further limitation of both trials was having only a median follow-up of roughly 10 years, which we believe is of inadequate duration for an often slowly progressive cancer such as prostate cancer. The Task Force gave little weight to the longer Göteborg Randomised Population-Based Prostate-Cancer Screening Trial, which had better protocol compliance and in which the interim 14-year median follow-up results showed a greater (44%) reduction in death from prostate cancer for the screened group (risk ratio, 0.56 [CI 0.39 to 0.82; P#= 0.002]) (9). In addition to misinterpreting the potential effect of the limitations of the 2 largest screening trails, we believe that the Task Force had other flaws in its reasoning. First, it overlooked the fact that diagnostic procedures and related complications occur in unscreened populations as well, and at a later stage of cancer discovery. In the ERSPC trial, highergrade cancer (Gleason score 7) was more common in the control group (45.2%) versus the screened group (27.8%), with a 40% greater incidence of locally advanced and

3 metastatic cancer (4). Undeniably, victims of advanced prostate cancer endure more invasive and harmful procedures than those with organ-confined disease. Second, the Task Force analysis focused on mortality and ignored the substantial illness associated with living with advanced cancer. Disseminated prostate cancer is characterized by painful bone metastases, pathologic fractures, and urinary tract obstruction. A comprehensive comparative analysis of benefits and harms in screened and control populations should consider the complications of advanced cancer, which could be more common in unscreened groups. Third, we believe that the Task Force recommendation lacks adequate consideration of high-risk populations, including men with a family history of prostate cancer and men of African descent, who have a 1.4-times higher risk for being diagnosed with and 2- to 3- times higher risk for dying of prostate cancer compared with European American men (10). Fourth, the USPSTF did not adequately emphasize epidemiologic data that shows that since the widespread use of PSA testing began in the early 1990s, there has been a 40% decrease in prostate cancer deaths and a 75% decrease in presentation with advanced disease at initial diagnosis, which is attributed, in large part, to PSA screening (11). A recent National Institutes of Health Consensus Development Conference concluded that prior to the adoption of PSA screening, the majority of prostate cancer was detected because of symptoms of advanced cancer or a nodule found on digital rectal examination. The symptomatic tumors were usually high-grade, advanced, and often lethal (12). Finally, the Task Force recommendation opposes PSA testing regardless of age. The expected life span for a man aged 75 years is approximately 10 years but reaches 30 years for men at age 45 to 50 years. It is plausible that many men aged 75 years or older will die of other causes before developing metastatic prostate cancer, but the current recommendation, arguably to avoid adverse effects of screening, could result in delayed diagnosis of curable cancer in young men who may then present with advanced disease, illness, and death. The Task Force recommendation relies solely on mortality data from the PLCO and the ERSPC and early data from the Prostate Cancer Intervention Versus Observation Trial (1). We believe that studies with only a 10-year median follow-up are insufficient to dictate how a man with prostate cancer aged 50 to 60 years should be treated. The recommendations of the USPSTF carry considerable weight with Medicare and other third-party insurers and could affect the health and lives of men at high risk for lifethreatening disease. We believe that elimination of reimbursement for PSA testing would take us back to an era when prostate cancer was often discovered at advanced and incurable stages. At this point, we suggest that physicians review the evidence, follow the continuing dialogue closely, and individualize prostate cancer screening decisions on the basis of informed patient preferences. From Northwestern University Feinberg School of Medicine, Chicago, Illinois; Brigham and Women s Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts; Creighton University School of Medicine, Omaha, Nebraska; Duke Cancer Institute and Duke University School of Medicine, Durham, North Carolina; and James Buchanan Brady Urologic Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland.

4 Potential Conflicts of Interest: Disclosures can be viewed at Requests for Single Reprints: Marc S. Rendell, MD, The Creighton Diabetes Center, 601 North 30th Street, Omaha, NE 68131; , Current Author Addresses: Dr. Catalona: 675 North St. Clair Street, Suite , Chicago, Illinois Dr. D Amico: Brigham and Women s Hospital, 75 Francis Street #Asb1, Boston, MA Dr. Fitzgibbons: Skyline Medical Center, 1908 North 203rd Street Suite 2, Elkhorn, NE Dr. Kosoko-Lasaki: Health Sciences Office of Multicultural and Community Affairs, Hixson Lied Building, Suite L23, Creighton University, 2500 California Plaza, Omaha, NE Dr. Leslie: Department of Surgery, Division of Urology, Suite 3700, 601 North 30th Street, Omaha, NE Dr. Lynch: Hereditary Cancer Center and Department of Preventive Medicine, Creighton University, 2500 California Plaza, Omaha, NE Dr. Moul: Division of Urologic Surgery, DUMC 3707-Room 1562 Duke South, Duke University Medical Center, Durham, NC Dr. Rendell: The Creighton Diabetes Center, 601 North 30th Street, Omaha, NE Dr. Walsh: Johns Hopkins Hospital, Park 224, Baltimore MD Author Contributions: Conception and design: W.J. Catalona, W.F. Fitzgibbons, J.W. Moul, M.S. Rendell, P.C. Walsh. Analysis and interpretation of the data: W.J. Catalona, A.V. D Amico, S.W. Leslie, H.T. Lynch, M.S. Rendell, P.C. Walsh. Drafting of the article: W.J. Catalona, A.V. D Amico, S.W. Leslie, J.W. Moul, M.S. Rendell, P.C. Walsh. Critical revision of the article for important intellectual content: W.J. Catalona, A.V. D Amico, W.F. Fitzgibbons, S.W. Leslie, J.W. Moul, M.S. Rendell, P.C. Walsh. Final approval of the article: W.J. Catalona, A.V. D Amico, W.F. Fitzgibbons, O. Kosoko- Lasaki, S.W. Leslie, H.T. Lynch, J.W. Moul, M.S. Rendell, P.C. Walsh. Administrative, technical, or logistic support: S.W. Leslie, M.S. Rendell. Collection and assembly of data: W.J. Catalona, A.V. D Amico, S.W. Leslie. References 1. Moyer VA; U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2012;157: -. [Epub ahead of print 22 May 2012]. 2. Chou R, Croswell JM, Dana T, Bougatsos C, Blazina I, Fu R, et al. Screening for prostate cancer: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155: [PMID: ] 3. Andriole GL, Crawford ED, Grubb RL 3rd, Buys SS, Chia D, Church TR, et al; PLCO Project Team. Prostate cancer screening in the randomized Prostate, Lung, Colorectal,

5 and Ovarian Cancer Screening Trial: mortality results after 13 years of follow-up. J Natl Cancer Inst. 2012;104: [PMID: ] 4. Schröder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, et al; ERSPC Investigators. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009;360: [PMID: ] 5. Schröder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, et al; ERSPC Investigators. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med. 2012;366: [PMID: ] 6. Bill-Axelson A, Holmberg L, Ruutu M, Garmo H, Stark JR, Busch C, et al; SPCG-4 Investigators. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med. 2011;364: [PMID: ] 7. Pinsky PF, Blacka A, Kramer BS, Miller A, Prorok PC, Berg C. Assessing contamination and compliance in the prostate component of the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. Clin Trials. 2010;7: [PMID: ] 8. Roobol MJ, Kerkhof M, Schröder FH, Cuzick J, Sasieni P, Hakama M, et al. Prostate cancer mortality reduction by prostate-specific antigen-based screening adjusted for nonattendance and contamination in the European Randomised Study of Screening for Prostate Cancer (ERSPC). Eur Urol. 2009;56: [PMID: ] 9. Hugosson J, Carlsson S, Aus G, Bergdahl S, Khatami A, Lodding P, et al. Mortality results from the Göteborg randomised population-based prostate-cancer screening trial. Lancet Oncol. 2010;11: [PMID: ] 10. Chornokur G, Dalton K, Borysova ME, Kumar NB. Disparities at presentation, diagnosis, treatment, and survival in African American men, affected by prostate cancer. Prostate. 2011;71: [PMID: ] 11. Etzioni R, Tsodikov A, Mariotto A, Szabo A, Falcon S, Wegelin J, et al. Quantifying the role of PSA screening in the US prostate cancer mortality decline. Cancer Causes Control. 2008;19: [PMID: ] 12. Ganz PA, Barry JM, Burke W, Col NF, Corso PS, Dodson E, et al. National Institutes of Health State-of-the-Science Conference: Role of Active Surveillance in the Management of Men With Localized Prostate Cancer. Ann Intern Med. 2012;156: [PMID: ] Related article

4/8/13. Pre-test Audience Response. Prostate Cancer 2012. Screening and Treatment of Prostate Cancer: The 2013 Perspective

4/8/13. Pre-test Audience Response. Prostate Cancer 2012. Screening and Treatment of Prostate Cancer: The 2013 Perspective Pre-test Audience Response Screening and Treatment of Prostate Cancer: The 2013 Perspective 1. I do not offer routine PSA screening, and the USPSTF D recommendation will not change my practice. 2. In light

More information

Cancer in Primary Care: Prostate Cancer Screening. How and How often? Should we and in which patients?

Cancer in Primary Care: Prostate Cancer Screening. How and How often? Should we and in which patients? Cancer in Primary Care: Prostate Cancer Screening How and How often? Should we and in which patients? PLCO trial (Prostate, Lung, Colorectal and Ovarian) Results In the screening group, rates of compliance

More information

U.S. Preventive Services Task Force

U.S. Preventive Services Task Force U.S. Preventive Services Task Force Screening for Prostate Cancer: Recommendation Statement See related Putting Prevention into Practice on page 283. This summary is one in a series excerpted from the

More information

Prostate-Specific Antigen Based Screening: Controversy and Guidelines

Prostate-Specific Antigen Based Screening: Controversy and Guidelines Prostate-Specific Antigen Based Screening: Controversy and Guidelines Eric H. Kim and Gerald L. Andriole Institutional Address: Washington University School of Medicine 4960 Children's Place Campus Box

More information

Prostate Cancer Screening Guideline

Prostate Cancer Screening Guideline Prostate Cancer Screening Guideline Contents Prevention 2 Screening Recommendations 2 Shared Decision Making 2 Test Recommendations 3 Follow-up/Referral 3 Treatment Overview 4 Evidence Summary 4 References

More information

PSA screening in asymptomatic men the debate continues www.bpac.org.nz keyword: psa

PSA screening in asymptomatic men the debate continues www.bpac.org.nz keyword: psa PSA screening in asymptomatic men the debate continues www.bpac.org.nz keyword: psa Key messages: PSA is present in the benign and malignant prostate There is currently no national screening programme

More information

Prostate Cancer: Screening Update Middlesex Hospital Cancer Center Comprehensive Prostate Cancer Program

Prostate Cancer: Screening Update Middlesex Hospital Cancer Center Comprehensive Prostate Cancer Program Prostate Cancer: Screening Update Middlesex Hospital Cancer Center Comprehensive Prostate Cancer Program Edward G. Myer, M.D. Middlesex Urology, P.C. October 15, 2015 Middlesex Hospital Cancer Center Comprehensive

More information

The use of PSA testing in general practice. Ross Lawrenson Waikato Clinical Campus University of Auckland

The use of PSA testing in general practice. Ross Lawrenson Waikato Clinical Campus University of Auckland The use of PSA testing in general practice Ross Lawrenson Waikato Clinical Campus University of Auckland The Team Prostate cancer American Joint Committee on Cancer (AJCC) Staging System The AJCC staging

More information

Cancer research in the Midland Region the prostate and bowel cancer projects

Cancer research in the Midland Region the prostate and bowel cancer projects Cancer research in the Midland Region the prostate and bowel cancer projects Ross Lawrenson Waikato Clinical School University of Auckland MoH/HRC Cancer Research agenda Lung cancer Palliative care Prostate

More information

Prostate Cancer Screening

Prostate Cancer Screening Prostate Cancer Screening Bruce L. Houghton, MD Associate Professor of Medicine Division of General Medicine Department of Internal Medicine Creighton University School of Medicine http://en.wikipedia.org/wiki/image:prostatelead.jpg

More information

Prostate Cancer Screening in Taiwan: a must

Prostate Cancer Screening in Taiwan: a must Prostate Cancer Screening in Taiwan: a must 吳 俊 德 基 隆 長 庚 醫 院 台 灣 醫 學 會 105 th What is the PSA test? The blood level of PSA is often elevated in men with prostate cancer, and the PSA test was originally

More information

Screening for Prostate Cancer: Understanding the Evidence, Differences in Screening Guidelines, and Future Directions

Screening for Prostate Cancer: Understanding the Evidence, Differences in Screening Guidelines, and Future Directions Screening for Prostate Cancer: Understanding the Evidence, Differences in Screening Guidelines, and Future Directions American Council of Life Insurers Medical Section Annual Meeting February 24, 2013

More information

Prostate Cancer Screening: Are We There Yet? March 2010 Andrew M.D. Wolf, MD University of Virginia School of Medicine

Prostate Cancer Screening: Are We There Yet? March 2010 Andrew M.D. Wolf, MD University of Virginia School of Medicine Prostate Cancer Screening: Are We There Yet? March 2010 Andrew M.D. Wolf, MD University of Virginia School of Medicine Case #1 A 55 yo white man with well-controlled hypertension presents for his annual

More information

See also: Web-Only CME quiz

See also: Web-Only CME quiz Guidance Statements Screening for Prostate Cancer: A Guidance Statement From the Clinical Guidelines Committee of the American College of Physicians Amir Qaseem, MD, PhD, MHA; Michael J. Barry, MD; Thomas

More information

Official reprint from UpToDate www.uptodate.com 2013 UpToDate

Official reprint from UpToDate www.uptodate.com 2013 UpToDate Official reprint from UpToDate www.uptodate.com 2013 UpToDate The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek

More information

Prostate-Specific Antigen (PSA) Based Population Screening for Prostate Cancer: OHTAC Recommendation

Prostate-Specific Antigen (PSA) Based Population Screening for Prostate Cancer: OHTAC Recommendation Prostate-Specific Antigen (PSA) Based Population Screening for Prostate Cancer: OHTAC Recommendation HEALTH QUALITY ONTARIO ONTARIO HEALTH TECHNOLOGY ADVISORY COMMITTEE RECOMMENDATION OHTAC recommends

More information

Defending PSA Re-Thinking the USPSTF Recommendations for Prostate Cancer Screening Steven Bereta, MS, RN, FNP-C

Defending PSA Re-Thinking the USPSTF Recommendations for Prostate Cancer Screening Steven Bereta, MS, RN, FNP-C Defending PSA Re-Thinking the USPSTF Recommendations for Prostate Cancer Screening Steven Bereta, MS, RN, FNP-C Disclosure I do not have affiliations with any corporate organization that may constitute

More information

PSA Screening and the USPSTF Understanding the Controversy

PSA Screening and the USPSTF Understanding the Controversy PSA Screening and the USPSTF Understanding the Controversy Peter C. Albertsen Division of Urology University of Connecticut Farmington, CT, USA USPSTF Final Report 1 Four Key Questions 1. Does PSA based

More information

Clinical Practice Guidelines

Clinical Practice Guidelines Clinical Practice Guidelines Prostate Cancer Screening CareMore Quality Management CareMore Health System adopts Clinical Practice Guidelines for the purpose of improving health care and reducing unnecessary

More information

The PLCO Trial Not a comparison of Screening vs no Screening

The PLCO Trial Not a comparison of Screening vs no Screening PSA Screening: Science, Politics and Uncertainty David F. Penson, MD, MPH Hamilton and Howd Chair of Urologic Oncology Professor and Chair, Department of Urologic Surgery Director, Center for Surgical

More information

Prostate Cancer PSA Controversy and Emergence of Active Surveillance

Prostate Cancer PSA Controversy and Emergence of Active Surveillance Prostate Cancer PSA Controversy and Emergence of Active Surveillance Christopher J. Kane MD Professor of Surgery, Chief of Urology C Lowell and JoEllen Parsons Chair in Urology Disclosures NCI Kidney Cancer

More information

PSA: Prostate Cancer Screening

PSA: Prostate Cancer Screening PSA: Prostate Cancer Screening 42 nd Annual Convention of the Philippines College of Physicians May 7, 2012, SMX Convention Center Jose Albert Cruz Reyes III, MD, FPCS, FPUA, DPBU Institute of Urology

More information

Prostate Cancer Screening: What We ve Learned and Where we should go

Prostate Cancer Screening: What We ve Learned and Where we should go Prostate Cancer Screening: What We ve Learned and Where we should go Gerald L. Andriole, MD Robert K. Royce Distinguished Professor Chief of Urologic Surgery Siteman Cancer Center Washington University

More information

Virtual Mentor American Medical Association Journal of Ethics January 2011, Volume 13, Number 1: 10-15.

Virtual Mentor American Medical Association Journal of Ethics January 2011, Volume 13, Number 1: 10-15. Virtual Mentor American Medical Association Journal of Ethics January 2011, Volume 13, Number 1: 10-15. CLINICAL CASE The Debate Over Prostate Cancer Screening Guidelines Commentary by Karen E. Hoffman,

More information

Prostate Cancer Screening Recommendations from the US Preventive Services Task Force: Evidence and implementation to optimize health outcomes

Prostate Cancer Screening Recommendations from the US Preventive Services Task Force: Evidence and implementation to optimize health outcomes Prostate Cancer Screening Recommendations from the US Preventive Services Task Force: Evidence and implementation to optimize health outcomes Timothy J. Wilt, MD, MPH, MACP University of Minnesota and

More information

Update on Prostate Cancer Screening Guidelines

Update on Prostate Cancer Screening Guidelines www.medscape.com Update on Prostate Cancer Screening Guidelines Christine Gonzalez, PharmD, CHHC US Pharmacist Abstract and Introduction Introduction In the United States, prostate cancer is the most common

More information

The Centers for Medicare & Medicaid Services (CMS) seeks stakeholder comments on the following clinical quality measure under development:

The Centers for Medicare & Medicaid Services (CMS) seeks stakeholder comments on the following clinical quality measure under development: The Centers for Medicare & Medicaid Services (CMS) seeks stakeholder comments on the following clinical quality measure under development: Title: Non-Recommended PSA-Based Screening Description: The percentage

More information

Examining the Efficacy of Screening with Prostate- Specific Antigen Testing in Reducing Prostate Cancer Mortality

Examining the Efficacy of Screening with Prostate- Specific Antigen Testing in Reducing Prostate Cancer Mortality St. Catherine University SOPHIA Master of Arts in Nursing Theses Nursing 5-2012 Examining the Efficacy of Screening with Prostate- Specific Antigen Testing in Reducing Prostate Cancer Mortality Rachel

More information

BY ELECTRONIC SUBMISSION

BY ELECTRONIC SUBMISSION November 20, 2015 BY ELECTRONIC SUBMISSION Patrick Conway, MD Deputy Administrator for Innovation & Quality Chief Medical Officer Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore,

More information

PSA Testing 101. Stanley H. Weiss, MD. Professor, UMDNJ-New Jersey Medical School. Director & PI, Essex County Cancer Coalition. weiss@umdnj.

PSA Testing 101. Stanley H. Weiss, MD. Professor, UMDNJ-New Jersey Medical School. Director & PI, Essex County Cancer Coalition. weiss@umdnj. PSA Testing 101 Stanley H. Weiss, MD Professor, UMDNJ-New Jersey Medical School Director & PI, Essex County Cancer Coalition weiss@umdnj.edu September 23, 2010 Screening: 3 tests for PCa A good screening

More information

ERSPC and PLCO Prostate Cancer Screening Studies: What Are the Differences?

ERSPC and PLCO Prostate Cancer Screening Studies: What Are the Differences? EUROPEAN UROLOGY 58 (2010) 46 52 available at www.sciencedirect.com journal homepage: www.europeanurology.com Editorial ERSPC and PLCO Prostate Cancer Screening Studies: What Are the Differences? Fritz

More information

The Prostate-Specific Antigen (PSA) Test: Questions and Answers

The Prostate-Specific Antigen (PSA) Test: Questions and Answers The Prostate-Specific Antigen (PSA) Test: Questions and Answers Key Points Prostate-specific antigen (PSA) is a protein produced by the cells of the prostate gland. The PSA test measures the level of PSA

More information

Prostate cancer. Christopher Eden. The Royal Surrey County Hospital, Guildford & The Hampshire Clinic, Old Basing.

Prostate cancer. Christopher Eden. The Royal Surrey County Hospital, Guildford & The Hampshire Clinic, Old Basing. Prostate cancer Christopher Eden The Royal Surrey County Hospital, Guildford & The Hampshire Clinic, Old Basing. Screening Screening men for PCa (prostate cancer) using PSA (Prostate Specific Antigen blood

More information

1. What is the prostate-specific antigen (PSA) test?

1. What is the prostate-specific antigen (PSA) test? 1. What is the prostate-specific antigen (PSA) test? Prostate-specific antigen (PSA) is a protein produced by the cells of the prostate gland. The PSA test measures the level of PSA in the blood. The doctor

More information

7. Prostate cancer in PSA relapse

7. Prostate cancer in PSA relapse 7. Prostate cancer in PSA relapse A patient with prostate cancer in PSA relapse is one who, having received a primary treatment with intent to cure, has a raised PSA (prostate-specific antigen) level defined

More information

PSA Screening for Prostate Cancer Information for Care Providers

PSA Screening for Prostate Cancer Information for Care Providers All men should know they are having a PSA test and be informed of the implications prior to testing. This booklet was created to help primary care providers offer men information about the risks and benefits

More information

Summary of Harms from Screening and Treatment for Prostate Cancer

Summary of Harms from Screening and Treatment for Prostate Cancer DRAFT: Advice from Dr John Childs MoH advisor Summary of Harms from Screening and Treatment for Prostate Cancer There are minimal risks directly attributable to PSA testing or transrectal ultrasound (TRUS)

More information

PSA Testing for Prostate Cancer An information sheet for men considering a PSA Test

PSA Testing for Prostate Cancer An information sheet for men considering a PSA Test PSA Testing for Prostate Cancer An information sheet for men considering a PSA Test What is the aim of this leaflet? Prostate cancer is a serious condition. The PSA test, which can give an early indication

More information

DECISION AID TOOL PROSTATE CANCER SCREENING WITH PSA TESTING

DECISION AID TOOL PROSTATE CANCER SCREENING WITH PSA TESTING DECISION AID TOOL PROSTATE CANCER SCREENING WITH PSA TESTING This booklet is what is often called a decision aid. The goals of a decision aid are to help people better understand their medical choices

More information

Modeling Drivers of Cost and Benefit for Policy Development in Cancer

Modeling Drivers of Cost and Benefit for Policy Development in Cancer Modeling Drivers of Cost and Benefit for Policy Development in Cancer Harms? Benefits? Costs? Ruth Etzioni Fred Hutchinson Cancer Research Center Seattle, Washington The USPSTF recommends against routine

More information

Prostate Cancer Screening 18 th February 2016

Prostate Cancer Screening 18 th February 2016 Prostate Cancer Screening 18 th February 2016 Mira Keyes MD FRCPC Clinical Professor Radiation Oncology Department of Surgery UBC Head, BCCA prostate Brachytherapy Program Vancouver Cancer Centre, BC cancer

More information

Thomas A. Kollmorgen, M.D. Oregon Urology Institute

Thomas A. Kollmorgen, M.D. Oregon Urology Institute Thomas A. Kollmorgen, M.D. Oregon Urology Institute None 240,000 new diagnosis per year, and an estimated 28,100 deaths (2012) 2 nd leading cause of death from cancer in U.S.A. Approximately 1 in 6 men

More information

Update on Prostate Cancer Current Controversies Lucas Jacomides, M.D.

Update on Prostate Cancer Current Controversies Lucas Jacomides, M.D. Update on Prostate Cancer Current Controversies Lucas Jacomides, M.D. Assistant Professor of Surgery, Texas A&M Health Science Center College of Medicine Director of Urology, Scott & White-Round Rock The

More information

Controversites: Screening for Prostate Cancer in Older Adults

Controversites: Screening for Prostate Cancer in Older Adults Controversites: Screening for Prostate Cancer in Older Adults William Dale, MD, PhD University of Chicago Sections of Geriatrics & Palliative Medicine and Hematology/Oncology Director, Specialized Oncology

More information

The PSA Test for Prostate Cancer Screening:

The PSA Test for Prostate Cancer Screening: For more information, please contact your local VA Medical Center or Health Clinic. U.S. Department of Veterans Affairs Veterans Health Administration Patient Care Services Health Promotion and Disease

More information

Screening for Prostate Cancer with Prostate Specific Antigen

Screening for Prostate Cancer with Prostate Specific Antigen Screening for Prostate Cancer with Prostate Specific Antigen January 18, 2013 ERSC Project Lead Investigator: Donna Ciliska ERSC Project Staff: Donna Fitzpatrick-Lewis, Judy Brown, Ali Usman and Maureen

More information

The 4Kscore blood test for risk of aggressive prostate cancer

The 4Kscore blood test for risk of aggressive prostate cancer The 4Kscore blood test for risk of aggressive prostate cancer Prostate cancer tests When to use the 4Kscore Test? Screening Prior to 1 st biopsy Prior to negative previous biopsy Prognosis in Gleason 6

More information

Position Statement on Testing for Prostate Cancer

Position Statement on Testing for Prostate Cancer 1 Position Statement on Testing for Prostate Cancer 2 Key Messages There is still no clear evidence to recommend a national screening programme for prostate cancer. General practitioners (GP s) and other

More information

In 2014, about 233,000 American men. Prostate Cancer Screening

In 2014, about 233,000 American men. Prostate Cancer Screening ELIE MULHEM, MD, Oakland University William Beaumont School of Medicine, Sterling Heights, Michigan NIKOLAUS FULBRIGHT, MD, Providence Hospital, South Lyon, Michigan NORAH DUNCAN, MD, Oakland University

More information

Prostate-Specific Antigen-Based Screening for Prostate Cancer: An Evidence Update for the U.S. Preventive Services Task Force

Prostate-Specific Antigen-Based Screening for Prostate Cancer: An Evidence Update for the U.S. Preventive Services Task Force Evidence Synthesis Number 90 Prostate-Specific Antigen-Based Screening for Prostate Cancer: An Evidence Update for the U.S. Preventive Services Task Force Prepared for: Agency for Healthcare Research and

More information

Early Prostate Cancer: Questions and Answers. Key Points

Early Prostate Cancer: Questions and Answers. Key Points CANCER FACTS N a t i o n a l C a n c e r I n s t i t u t e N a t i o n a l I n s t i t u t e s o f H e a l t h D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s Early Prostate Cancer:

More information

Linköping University Post Print. Randomised prostate cancer screening trial: 20 year follow-up

Linköping University Post Print. Randomised prostate cancer screening trial: 20 year follow-up Linköping University Post Print Randomised prostate cancer screening trial: 20 year follow-up Gabriel Sandblom, Eberhard Varenhorst, Johan Rosell, Owe Lofman and Per Carlsson N.B.: When citing this work,

More information

Early Detection of Prostate Cancer: Sunnybrook Health Sciences Centre Professor of Surgery University of Toronto

Early Detection of Prostate Cancer: Sunnybrook Health Sciences Centre Professor of Surgery University of Toronto Early Detection of Prostate Cancer: How to do it smart Laurence Klotz Sunnybrook Health Sciences Centre Professor of Surgery University of Toronto If screening was a pill: You are a 60 year old male and

More information

Furthering the prostate cancer screening debate (prostate cancer specific mortality and associated risks)

Furthering the prostate cancer screening debate (prostate cancer specific mortality and associated risks) review Furthering the prostate cancer screening debate (prostate cancer specific mortality and associated risks) G. Michael Allan MD, CCFP; * Michael P. Chetner, MD, MSc, FRCSC, FACS; Bryan J. Donnelly,

More information

Prostate cancer screening- pro and contra, lessons from the ERSPC study

Prostate cancer screening- pro and contra, lessons from the ERSPC study Prostate cancer screening- pro and contra, lessons from the ERSPC study Are we ready for a population-based screening program? Dr. Pim J.van Leeuwen Erasmus MC, Rotterdam, The Netherlands On behalf of

More information

Published Ahead of Print on July 16, 2012 as 10.1200/JCO.2012.43.3441. J Clin Oncol 30. 2012 by American Society of Clinical Oncology

Published Ahead of Print on July 16, 2012 as 10.1200/JCO.2012.43.3441. J Clin Oncol 30. 2012 by American Society of Clinical Oncology Published Ahead of Print on July 16, 2012 as 10.1200/JCO.2012.43.3441 The latest version is at http://jco.ascopubs.org/cgi/doi/10.1200/jco.2012.43.3441 JOURNAL OF CLINICAL ONCOLOGY A S C O S P E C I A

More information

Prostate Cancer: Current Evidence Weighs Against Population Screening

Prostate Cancer: Current Evidence Weighs Against Population Screening Prostate Cancer: Current Evidence Weighs Against Population Screening Peter Boyle, PhD, DSc, President, International Prevention Research Institute, Lyon, France, and Otis W. Brawley, MD, Chief Medical

More information

The U.S. Preventive Services Task Force (USPSTF) makes

The U.S. Preventive Services Task Force (USPSTF) makes Annals of Internal Medicine Clinical Guidelines Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement U.S. Preventive Services Task Force* Description: Update of the

More information

PSA screening: Controversies and Guidelines

PSA screening: Controversies and Guidelines PSA screening: Controversies and Guidelines John Phillips, MD, FACS Department of Urology Urology Center of Westchester New York Medical College Historical PerspecGve Cancer of the prostate, although rare,

More information

Screening for Prostate Cancer

Screening for Prostate Cancer Screening for Prostate Cancer Review against programme appraisal criteria for the UK National Screening Committee (UK NSC) Version 1: This document summarises the work of ScHARR 1 2 and places it against

More information

PSA: Screening for Prostate Cancer in Older Adults

PSA: Screening for Prostate Cancer in Older Adults PSA: Screening for Prostate Cancer in Older Adults William Dale, MD, PhD University of Chicago Sections of Geriatrics & Palliative Medicine and Hematology/Oncology Director, Specialized Oncology Care &

More information

Making sense of prostate cancer screening

Making sense of prostate cancer screening Making sense of prostate cancer screening Piotr Czaykowski MD MSc FRCPC Medical Oncology, CancerCare Manitoba University of Manitoba Disclosure of Potential for Conflict of Interest Name of presenter Name

More information

Update on Prostate Cancer: Screening, Diagnosis, and Treatment Making Sense of the Noise and Directions Forward

Update on Prostate Cancer: Screening, Diagnosis, and Treatment Making Sense of the Noise and Directions Forward Update on Prostate Cancer: Screening, Diagnosis, and Treatment Making Sense of the Noise and Directions Forward 33 rd Annual Internal Medicine Update December 5, 2015 Ryan C. Hedgepeth, MD, MS Chief of

More information

Prostate Cancer Screening Clinical Practice Guideline. Approved by the National Guideline Directors November, 2013

Prostate Cancer Screening Clinical Practice Guideline. Approved by the National Guideline Directors November, 2013 Prostate Cancer Screening Clinical Practice Guideline This guideline is informational only. It is not intended or designed as a substitute for the reasonable exercise of independent clinical judgment by

More information

Prostate Cancer Information and Facts

Prostate Cancer Information and Facts Prostate Cancer Information and Facts Definition Prostate cancer is cancer that starts in the prostate gland. The prostate is a small, walnutsized structure that makes up part of a man's reproductive system.

More information

Key Messages for Healthcare Providers

Key Messages for Healthcare Providers Cancer Care Ontario: Prostate Cancer Screening with the Prostate- Specific Antigen (PSA) Test Key Messages for Healthcare Providers Considerations for men at average risk Avoid prostate-specific antigen

More information

PSA Test Provides the Early Prostate Cancer Detection That Has Saved the Life of Thousands of Men

PSA Test Provides the Early Prostate Cancer Detection That Has Saved the Life of Thousands of Men PSA Test Provides the Early Prostate Cancer Detection That Has Saved the Life of Thousands of Men Table of Contents 1. What the research shows on the effectiveness of the PSA test p. 2 2. PSA test guidelines

More information

Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement DRAFT

Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement DRAFT Page 1 of 11 Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement DRAFT Summary of Recommendation and Evidence The U.S. Preventive Services Task Force (USPSTF) recommends

More information

Role of MRI in the Diagnosis of Prostate Cancer, A Proposal

Role of MRI in the Diagnosis of Prostate Cancer, A Proposal Clinical and Experimental Medical Sciences, Vol. 1, 2013, no. 3, 111 116 HIKARI Ltd, www.m-hikari.com Role of MRI in the Diagnosis of Prostate Cancer, A Proposal W. Akhter Research Fellow Urology, Bartshealth

More information

Prostate Cancer. Screening and Diagnosis. Screening. Pardeep Kumar Consultant Urological Surgeon

Prostate Cancer. Screening and Diagnosis. Screening. Pardeep Kumar Consultant Urological Surgeon The Royal Marsden Prostate Cancer Screening and Diagnosis Pardeep Kumar Consultant Urological Surgeon Prostate Cancer Screening and Diagnosis 08 02 2013 2 Screening 1 3 Q1.Lots of men have prostate cancer

More information

TO SCREEN OR NOT TO SCREEN: THE PROSTATE CANCER

TO SCREEN OR NOT TO SCREEN: THE PROSTATE CANCER TO SCREEN OR NOT TO SCREEN: THE PROSTATE CANCER DILEMMA Thomas J Stormont MD January 2012 http://www.youtube.com/watch?v=8jd 7bAHVp0A&feature=related related INTRODUCTION A government health panel (the

More information

Prostate Cancer Screening: Phantom menace to society. Folusho Ogunfiditimi, DM, MPH, PA-C Vattikuti Urology Institute Henry Ford Health System

Prostate Cancer Screening: Phantom menace to society. Folusho Ogunfiditimi, DM, MPH, PA-C Vattikuti Urology Institute Henry Ford Health System Prostate Cancer Screening: Phantom menace to society Folusho Ogunfiditimi, DM, MPH, PA-C Vattikuti Urology Institute Henry Ford Health System Objectives USPTF Recommendations on PSA testing Justification

More information

Guidance on Using Active Surveillance to Manage Men with Low-risk Prostate Cancer

Guidance on Using Active Surveillance to Manage Men with Low-risk Prostate Cancer Guidance on Using Active Surveillance to Manage Men with Low-risk Prostate Cancer Citation: Prostate Cancer Working Group and Ministry of Health. 2015. Guidance on Using Active Surveillance to Manage Men

More information

PSA I LOVE YOU: PROSTATE CANCER SCREENING IN IRELAND

PSA I LOVE YOU: PROSTATE CANCER SCREENING IN IRELAND PSA I LOVE YOU: PROSTATE CANCER SCREENING IN IRELAND Eimear Keane Fourth year Medicine, Trinity College Dublin Abstract Ireland has the second highest rate of prostate cancer (PCa) in Europe and this is

More information

Screening for Prostate Cancer

Screening for Prostate Cancer clinical practice Screening for Prostate Cancer Richard M. Hoffman, M.D., M.P.H. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies

More information

Screening for Prostate Cancer With the Prostate-Specific Antigen Test A Review of Current Evidence

Screening for Prostate Cancer With the Prostate-Specific Antigen Test A Review of Current Evidence Clinical Review & Education Review Screening for Prostate Cancer With the Prostate-Specific Antigen Test A Review of Current Evidence Julia H. Hayes, MD; Michael J. Barry, MD IMPORTANCE Prostate cancer

More information

PSA Screening For Prostate Cancer: Yes Or No?

PSA Screening For Prostate Cancer: Yes Or No? PSA Screening For Prostate Cancer: Yes Or No? The United States Preventive Services Task Force issued a recommendation that healthy men should no longer receive PSA testing as part of routine cancer screening.

More information

Guidelines for Cancer Prevention, Early detection & Screening. Prostate Cancer

Guidelines for Cancer Prevention, Early detection & Screening. Prostate Cancer Guidelines for Cancer Prevention, Early detection & Screening Prostate Cancer Intervention Comments & Recommendations For primary prevention, it has been suggested that diets low in meat & other fatty

More information

November 25, 2015. Albert L Siu, MD, MSPH Chair, US Preventive Services Task Force 5600 Fishers Lane, Mail Stop 06E53A Rockville, MD 20857

November 25, 2015. Albert L Siu, MD, MSPH Chair, US Preventive Services Task Force 5600 Fishers Lane, Mail Stop 06E53A Rockville, MD 20857 November 25, 2015 Men's Health Network P. O. Box 75972 Washington, D.C. 20013 202-543-MHN-1 (6461) Fax 202-543-2727 Albert L Siu, MD, MSPH Chair, US Preventive Services Task Force 5600 Fishers Lane, Mail

More information

Prostate cancer is the most common cause of death from cancer in men over age 75. Prostate cancer is rarely found in men younger than 40.

Prostate cancer is the most common cause of death from cancer in men over age 75. Prostate cancer is rarely found in men younger than 40. A.D.A.M. Medical Encyclopedia. Prostate cancer Cancer - prostate; Biopsy - prostate; Prostate biopsy; Gleason score Last reviewed: October 2, 2013. Prostate cancer is cancer that starts in the prostate

More information

The PSA Controversy: Defining It, Discussing It, and Coping With It

The PSA Controversy: Defining It, Discussing It, and Coping With It The PSA Controversy: Defining It, Discussing It, and Coping With It 11 TH ANNUAL SYMPOSIUM ON MEN S HEALTH June 12, 2013 The PSA Controversy Defining It, Discussing It and Coping With It As of May 2012,

More information

Focus on PSA Screening for Prostate Cancer Vol. 28 Supplement, February 2012. Prostate Cancer: Should We Be Screening?

Focus on PSA Screening for Prostate Cancer Vol. 28 Supplement, February 2012. Prostate Cancer: Should We Be Screening? Focus on PSA Screening for Prostate Cancer Vol. 28 Supplement, February 2012 Prostate Cancer: Should We Be Screening? INSIDE THIS ISSUE 2 Why the Controversy? 3 Active Surveillance 4 The Radical Prostatectomy

More information

Regional difference in cancer detection proportion in prostate cancer

Regional difference in cancer detection proportion in prostate cancer Title page Title: Regional difference in cancer detection proportion in prostate cancer screening by a local municipality in Japan. Chie Koizumi, Takahiro Suetomi, Taeko Matsuoka, Atsushi Ikeda, Tomokazu

More information

2010 SITE REPORT St. Joseph Hospital PROSTATE CANCER

2010 SITE REPORT St. Joseph Hospital PROSTATE CANCER 2010 SITE REPORT St. Joseph Hospital PROSTATE CANCER Humboldt County is located on the Redwood Coast of Northern California. U.S census data for 2010 reports county population at 134,623, an increase of

More information

Diagnosis of Prostate Cancer: The Role of Diagnostic Assessment Units

Diagnosis of Prostate Cancer: The Role of Diagnostic Assessment Units Diagnosis of Prostate Cancer: The Role of Diagnostic Assessment Units Patti Marchand, Patient Care Manager Dr. Audrey Li, Radiation Oncologist RS McLaughlin Durham Regional Cancer Centre December 3, 2014

More information

Screening for Prostate Cancer

Screening for Prostate Cancer Screening for Prostate Cancer It is now clear that screening for Prostate Cancer discovers the disease at an earlier and more curable stage. It is not yet clear whether this translates into reduced mortality

More information

Prostate Cancer Screening. A Decision Guide for African Americans

Prostate Cancer Screening. A Decision Guide for African Americans Prostate Cancer Screening A Decision Guide for African Americans This booklet was developed by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC). Published

More information

Review. Annals of Internal Medicine

Review. Annals of Internal Medicine Review Annals of Internal Medicine Screening for Prostate Cancer: A Review of the Evidence for the U.S. Preventive Services Task Force Roger Chou, MD; Jennifer M. Croswell, MD, MPH; Tracy Dana, MLS; Christina

More information

MEDICAL POLICY SUBJECT: PROSTATE CANCER SCREENING, DETECTION AND MONITORING

MEDICAL POLICY SUBJECT: PROSTATE CANCER SCREENING, DETECTION AND MONITORING MEDICAL POLICY PAGE: 1 OF: 8 If the member's subscriber contract excludes coverage for a specific service it is not covered under that contract. In such cases, medical policy criteria are not applied.

More information

Lung Cancer Screening

Lung Cancer Screening Lung Cancer Screening Ted Yamamoto, Harvard Medical School Year III Case Presentation 67 year old male Hypertension, but otherwise healthy Smokes 7-87 8 cigarettes per day, >50 pack year history Here for

More information

The 4Kscore blood test for risk of aggressive prostate cancer

The 4Kscore blood test for risk of aggressive prostate cancer The 4Kscore blood test for risk of aggressive prostate cancer Early detection of aggressive prostate cancer Challenges Serum PSA has a high false positive rate Over 1 million prostate biopsies performed

More information

Prostate cancer trends in Canada, 1995 to 2012

Prostate cancer trends in Canada, 1995 to 2012 Catalogue no.82-624 X ISSN 1925-6493 Health at a Glance by Lawrence Ellison Release date: April 25, 2016 How to obtain more information For information about this product or the wide range of services

More information

Oncology Annual Report: Prostate Cancer 2005 Update By: John Konefal, MD, Radiation Oncology

Oncology Annual Report: Prostate Cancer 2005 Update By: John Konefal, MD, Radiation Oncology Oncology Annual Report: Prostate Cancer 25 Update By: John Konefal, MD, Radiation Oncology Prostate cancer is the most common cancer in men, with 232,9 new cases projected to be diagnosed in the U.S. in

More information

PEER REVIEW HISTORY ARTICLE DETAILS VERSION 1 - REVIEW

PEER REVIEW HISTORY ARTICLE DETAILS VERSION 1 - REVIEW PEER REVIEW HISTORY BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form (http://bmjopen.bmj.com/site/about/resources/checklist.pdf)

More information

Cigna Medical Coverage Policy

Cigna Medical Coverage Policy Cigna Medical Coverage Policy Subject Prostate-Specific Antigen (PSA) Screening for Prostate Cancer Table of Contents Coverage Policy... 1 General Background... 2 Coding/Billing Information... 14 References...

More information

Update on Screening in Prostate Cancer Based on Recent Clinical Trials

Update on Screening in Prostate Cancer Based on Recent Clinical Trials Reviews on Recent Clinical Trials, 2011, 6, 00-00 1 Update on Screening in Prostate Cancer Based on Recent Clinical Trials Alessandro Sciarra*, Susanna Cattarino, Stefano Salciccia, Alessandro Gentilucci,

More information

An Introduction to PROSTATE CANCER

An Introduction to PROSTATE CANCER An Introduction to PROSTATE CANCER Being diagnosed with prostate cancer can be a life-altering experience. It requires making some very difficult decisions about treatments that can affect not only the

More information

Breast cancer screening and prevention: Update from the USPSTF

Breast cancer screening and prevention: Update from the USPSTF Breast cancer screening and prevention: Update from the USPSTF Mark H. Ebell MD, MS Member, USPSTF College of Public Health The University of Georgia What we re going to do today Overview of the USPSTF

More information

HEALTH NEWS PROSTATE CANCER THE PROSTATE

HEALTH NEWS PROSTATE CANCER THE PROSTATE HEALTH NEWS PROSTATE CANCER THE PROSTATE Prostate comes from the Greek meaning to stand in front of ; this is very different than prostrate which means to lie down flat. The prostate is a walnut-sized

More information

An Empirical Evaluation of Guidelines on Prostate-specific Antigen Velocity in Prostate Cancer Detection

An Empirical Evaluation of Guidelines on Prostate-specific Antigen Velocity in Prostate Cancer Detection DOI: 10.1093/jnci/djr028 ARTICLE JNCI djr028 MA JOURNAL NAME Art. No. CE Code The Author 2011. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

More information