**9.1 Material and methods**

From 1994 until the end of 2007 206 radical retropubic prostatectomies in Caucasian men suffering from prostate cancer were carried out in the Department of Urology in Zabrze, Medical University of Silesia in Katowice. The patients who underwent preoperative antiandrogen therapy, chemotherapy or radiotherapy were excluded from the research (29 patients).

177 patients were qualified for the research. In our group two types of data were subject to analysis. Preoperative data, such as: age, height, weight, BMI, PSA concentration (immunoenzymatic Elecsys test; Cobas 6000 Hitachi) and postoperative data: the extent of histopathologic differentiation of prostate tissue in Gleason score, extracapsular extension (pT3), the presence of lymph nodes metastases and the presence of positive surgical margins.

Patients are under constant control in the Hospital Outpatient Clinic, thanks to which data concerning progression (biochemical recurrence, local recurrence, death) were also collected and the cancer-specific survival time was determined. The total volume of plasma and the PSA mass were calculated on the basis of the formulas (Table 1) (Boer, 1984; Du Bois & Du Bois, 1916).


Table 1. The formulas to estimate plasma volume and PSA mass.

The group of 177 patients was divided according to:


The characteristics of each group is shown in tables 2 and 3.

The Influence of Obesity on Prostate Cancer Diagnosis and Treatment 27

**BMI (kg/m2) PSA concentration** 

14 (21,2%)

65 (58,5%)

> 1 (10%)

78 (46,7%)

> 9 (18%)

70 (55,1%)

> 15 (23%)

64 (57,1%)

> 5 (25%)

74 (47,1%)

1 (6,6%)

78 (48,1%)

**pT3** 

**Positive lymph nodes** 

**Positive surgical margin** 

**Biochemical recurrence** 

**Local recurrence** 

**Death** 

Wilcoxon test.

Yes <sup>12</sup> (18,1%)

No <sup>33</sup> (29,7%)

Yes <sup>2</sup> (20%)

No <sup>43</sup> (25,7%)

Yes <sup>13</sup> (26%)

No <sup>32</sup> (25,1%)

Yes <sup>13</sup> (20%)

No <sup>32</sup> (28,5%)

Yes <sup>4</sup> (20%)

No <sup>41</sup> (26,1%)

Yes <sup>1</sup> (6,6%)

No <sup>44</sup> (27,1%)

33 (50%)

62 (55,8%)

> 4 (40%)

91 (54,5%)

> 28 (56%)

67 (52,7%)

34 (52,3%)

61 (54,4%)

> 10 (50%)

85 (54,1%)

> 6 (40%)

89 (54,9%)

21 (31,9%)

16 (14,5%)

> 4 (40%)

33 (19,8%)

> 9 (18%)

> 28 (22%)

18 (27,6%)

19 (16,9%)

> 6 (30%)

31 (19,7%)

8 (53,3%)

29 (17,9%)

because the presence of metastases would distort the results of the observation.

Receiver operating characteristic (ROC) curves compared predictive variables.

statistical analysis has been calculated by means of StatSoft Statistica 8.0.

Table 3. Characteristics of patients in groups of BMI, PSA concentration and PSA mass.

In order to evaluate and compare the odds ratio of biochemical recurrence together with the elevated concentration and mass of the PSA, the model of logistic regression has been used. The model has been adjusted to Gleason score (<8 and ≥ 8) in postoperative specimen. As both the concentration and the PSA mass did not show normal distribution, the logarithmic (decimal) transformation of data has been performed. 10 patients who have been diagnosed with metastases in the surrounding lymph nodes have been removed from the model

Cancer-specific survival of patients has been evaluated by means of Kaplan-Meier analysis, while the significance of differences between them has been evaluated by means of Gehan's

For all statistical tests the critical level of significance has been adopted at p<0,05. The

I II III I II III I II III

32 (48,5%)

34 (30,6%)

> 5 (50%)

61 (36,5%)

> 27 (54%)

39 (30,7%)

30 (46,1%)

36 (32,1%)

> 9 (45%)

57 (36,3%)

10 (66,6%)

56 (34,5%)

20 (30,3%)

12 (10,9%)

> 4 (40%)

28 (16,7%)

> 14 (28%)

18 (14,1%)

20 (30,7%)

12 (10,7%)

> 6 (30%)

26 (16,5%)

4 (26,6%)

28 (17,2%)

**(ng/ml) PSA mass (µg)** 

13 (19,6%)

58 (52,2%)

> 1 (10%)

70 (41,9%)

> 7 (14%)

64 (50,3%)

14 (21,5%)

57 (50,8%)

> 5 (25%)

> 66 (42%)

> > 0 (0%)

71 (43,8%)

34 (51,5%)

44 (39,6%)

> 3 (30%)

75 (44,9%)

> 29 (58%)

49 (38,5%)

33 (50,7%)

45 (41,1%)

> 7 (35%)

71 (45,2%)

> 9 (60%)

69 (42,5%)

19 (28,7%)

9 (8,1%)

6 (60%)

22 (13,1%)

> 14 (28%)

> 14 (11%)

18 (27,6%)

10 (8,9%)

8 (40%)

20 (12,7%)

> 6 (40%)

22 (13,5%)


Table 2. Characteristics of patients in groups of BMI, PSA concentration and PSA mass.

All constant variables distributions were analyzed with regard to normality by means of Kolmogorov-Smirnov and Lilliefors tests. By means of descriptive statistics the following characteristics have been determined: mean or median, standard deviation as well as maximal and minimal value.

In order to determine differences between the groups, where variables are of categorical character, Chi-square test has been used. In order to determine differences between a number of independent groups, where continuous variables have distribution other than normal, Kruskal-Wallis test has been used.

In order to eliminate the influence of factors disrupting the correlation between BMI and PSA concentration, such as: age, the extent of prostate cancer differentiation in Gleason score, extracapsular extension (pT3) or positive surgical margins, multiple regression has been used to create a model which would describe the aforesaid relationship. The aforementioned disrupting factors have been incorporated into the model.

**Age (years)** 

**BMI (kg/m2)** 

**Plasma** 

**PSA** 

**volume (liters)** 

**concentration (ng/ml)** 

**PSA mass (µg)** 

range

range

range

normal, Kruskal-Wallis test has been used.

maximal and minimal value.

17,9-

2,8- 51,8

31,9- 156,6

24,9 25-29,9 30,1-

1,8- 61,7

6,5- 196,6

aforementioned disrupting factors have been incorporated into the model.

40,3

4,2-

**Gleason score** median 5 6 6 5 6 6 5 6 6

13,7- 129,5

All constant variables distributions were analyzed with regard to normality by means of Kolmogorov-Smirnov and Lilliefors tests. By means of descriptive statistics the following characteristics have been determined: mean or median, standard deviation as well as

In order to determine differences between the groups, where variables are of categorical character, Chi-square test has been used. In order to determine differences between a number of independent groups, where continuous variables have distribution other than

In order to eliminate the influence of factors disrupting the correlation between BMI and PSA concentration, such as: age, the extent of prostate cancer differentiation in Gleason score, extracapsular extension (pT3) or positive surgical margins, multiple regression has been used to create a model which would describe the aforesaid relationship. The

Table 2. Characteristics of patients in groups of BMI, PSA concentration and PSA mass.

**BMI (kg/m2) PSA (ng/ml) PSA mass (µg)** 

I II III I II III I II III

17,9- 40,3 22,1- 35

20,4-

64,2- 196,6

20- 37,5

61,7 1,8-9,6 9-21,8 18-

6,5- 29,8 30,3- 69,6

17,9- 40,3 22,1- 38

61,7

70,7- 196,6

mean 62,8 62,2 62,1 63 61,4 62,6 62,8 61,8 62,7 SD 6,7 5,9 6 5,7 6,9 5,5 5,8 6,5 6 range 50-76 48-74 49-71 49-74 48-76 52-72 49-74 48-76 52-72

mean 23,4 27,4 32,6 27,1 28 27,4 26,9 27,8 28,2 SD 1,4 1,3 2,3 2,9 4 3,3 2,9 3,6 4

> 20- 37,5

mean 3,1 3,2 3,45 3,2 3,3 3,2 3,2 3,2 3,2

SD 0,13 0,2 0,2 0,2 0,2 0,2 0,2 0,2 0,2 range 2,9-3,4 2,8-3,9 2,9-4,1 2,7-3,7 2,8-4,1 2,9-3,7 2,7-3,7 2,8-4,1 2,9-3,9

mean 12,8 14,1 14,2 6,4 14,2 31,3 6,1 14,1 32,6

SD 8,9 11,9 7,7 1,9 2,8 11,6 1,7 3,5 11,9

mean 56,6 46,2 48,9 20,8 47 101,1 19,7 46,2 106,7 SD 27,4 39 25,1 6,37 10,3 37,1 5,6 11,3 36,5

> 6,5- 32,7

19,8

30,3- 71

43,4 1,8-9,8 10-


Table 3. Characteristics of patients in groups of BMI, PSA concentration and PSA mass.

In order to evaluate and compare the odds ratio of biochemical recurrence together with the elevated concentration and mass of the PSA, the model of logistic regression has been used. The model has been adjusted to Gleason score (<8 and ≥ 8) in postoperative specimen. As both the concentration and the PSA mass did not show normal distribution, the logarithmic (decimal) transformation of data has been performed. 10 patients who have been diagnosed with metastases in the surrounding lymph nodes have been removed from the model because the presence of metastases would distort the results of the observation.

Cancer-specific survival of patients has been evaluated by means of Kaplan-Meier analysis, while the significance of differences between them has been evaluated by means of Gehan's Wilcoxon test.

Receiver operating characteristic (ROC) curves compared predictive variables.

For all statistical tests the critical level of significance has been adopted at p<0,05. The statistical analysis has been calculated by means of StatSoft Statistica 8.0.

The Influence of Obesity on Prostate Cancer Diagnosis and Treatment 29

The model of multiple regression has proved the lack of statistically significant correlation between preoperative PSA concentration and BMI (p = 0,99). The research has proved that the elevated preoperative value of PSA mass (p = 0,02) is the factor which influences the

cancer-specific survival of patients with prostate cancer after RP (Fig.3).

Fig. 3. Comparison of overall survival time (days) in patients with prostate cancer

Fig. 4. Three-dimensional model of logistic regression with two independent variables (Gleason score and decimal logarithm from the value of PSA mass) and dependent

dychotomic variable (biochemical recurrence).

depending on the PSA mass.

#### **9.2 Results**

The values PSA mass in the research has a statistically significant influence on extracapsular extension (p<0,001), the presence of metastases in the surrounding lymph nodes (p<0,001), the frequency of positive surgical margins (p<0,001), the presence of biochemical (p<0001) and local recurrence (p<0,001) and the rate of death (p<0,001).

The research has shown that BMI does not influence preoperative PSA concentration and PSA mass (Fig.1 and 2). Differences in preoperative PSA concentration between the 3 groups of patients are statistically insignificant (p = 0,28). The total plasma volume is higher in obese patients (p<0,001).

Fig. 1. Comparison of preoperative PSA concentration (ng/ml) in BMI groups.

Fig. 2. Comparison of preoperative PSA mass in BMI groups.

The values PSA mass in the research has a statistically significant influence on extracapsular extension (p<0,001), the presence of metastases in the surrounding lymph nodes (p<0,001), the frequency of positive surgical margins (p<0,001), the presence of biochemical (p<0001)

The research has shown that BMI does not influence preoperative PSA concentration and PSA mass (Fig.1 and 2). Differences in preoperative PSA concentration between the 3 groups of patients are statistically insignificant (p = 0,28). The total plasma volume is higher in

Fig. 1. Comparison of preoperative PSA concentration (ng/ml) in BMI groups.

Fig. 2. Comparison of preoperative PSA mass in BMI groups.

and local recurrence (p<0,001) and the rate of death (p<0,001).

**9.2 Results** 

obese patients (p<0,001).

The model of multiple regression has proved the lack of statistically significant correlation between preoperative PSA concentration and BMI (p = 0,99). The research has proved that the elevated preoperative value of PSA mass (p = 0,02) is the factor which influences the cancer-specific survival of patients with prostate cancer after RP (Fig.3).

Fig. 3. Comparison of overall survival time (days) in patients with prostate cancer depending on the PSA mass.

Fig. 4. Three-dimensional model of logistic regression with two independent variables (Gleason score and decimal logarithm from the value of PSA mass) and dependent dychotomic variable (biochemical recurrence).

The Influence of Obesity on Prostate Cancer Diagnosis and Treatment 31

Some authors suggest another factor, namely, lower PSA concentration in obese patients (Baillargeon et al., 2005). The consequence of the aforesaid correlation may impact on prostate cancer diagnosis and evaluation of progression after its radical treatment. Other

The authors who prove that obese patients are characterized by lower PSA concentration, refer to the phenomenon of hemodilution. The supporters of that theory claim that obesity is characterized by a larger amount of circulating blood, so theoretically the constant PSA mass circulating in the organism would be dissolved in a large amount of plasma, resulting

However, our research has not proved that the elevated BMI has a significant influence on the preoperative PSA concentration. In order to explain the inconsistency we will call upon racial differences between the analyzed groups. The following research has been done on a group of patients of Caucasian race, while the aforesaid research has been frequently based on ethnically heterogeneous groups. The cause of differences between the outcomes can result from the polymorphism of the androgen receptor which causes higher PSA concentration in Afro-Americans, as well as statistically significant bigger obesity of this group (Xu et al., 2002). The influence of ethnical differences can, of course, be dismissed by appropriate statistical manipulations, nevertheless, it seems that research done on

In order to exclude the potential influence of hemodilution on the PSA concentration, the PSA mass in each patient has been calculated. Thanks to mathematical formulas used to estimate the total amount of circulating blood, its amount can be quite precisely determined. It has to be underlined that the phenomenon of hemodilution in obese patients had no statistically significant influence on PSA concentration. Also, having excluded other factors influencing PSA concentration, such as: cancer differentiation in Gleason score, the extracapsular extension (pT3), positive surgical margins or the patient's age, no significant

However, comparing both parameters (PSA concentration and the PSA mass) it has to be stressed that the probability of biochemical recurrence after RP is better predicted by PSA mass, which surely results from the fact that the PSA mass includes the element eliminating the phenomenon of hemodilution. Despite the fact that both preoperative parameters "equally well" evaluate the progression after RP, the PSA mass seems to be a little more

correlation between BMI and the preoperative PSA concentration has been found.

sensitive parameter (which is indicated by the difference in the odds ratio and AUC).

b. more frequent diagnosis of metastases in the surrounding lymph nodes,

2. The preoperative PSA mass is a better predictor of biochemical recurrence after RP than

3. The total plasma volume is higher in obese patients, however, it does not influence the

1. Increased preoperative value of the PSA mass is connected with: a. more frequent cancer diagnosis of pT3 prostate cancer,

c. more frequent recognition of the positive surgical margin,

d. shorter cancer-specific survival time, e. higher percentage of progression.

preoperative PSA concentration significantly.

authors disclaim the abovementioned connection (Freedland et al., 2006).

homogenous groups is characterized by greater statistical power.

in a lower PSA concentration.

**9.4 Conclusions** 

PSA concentration.

The odds ratio of biochemical recurrence, with the PSA mass increased 10 times, is equal to 8,64 (95% CI: 2,54 – 29,3; p<0,001) (Fig. 4). The odds ratio of biochemical recurrence, with the PSA concentration increased 10 times, is equal to 7,66 (95% CI: 2,25 – 26; p<0,001).

ROC curves for preoperative PSA mass and PSA concentration showed an area under curve (AUC) of 0,72 and 0,65 respectively for biochemical recurrence after RP (Fig. 5). The difference between these two predictors (AUC) was statistically significant (p=0,04).

Fig. 5. ROC curves for PSA mass as a preoperative predictor of biochemical recurrence after RP (Area Under Curve - 0,72).

### **9.3 Discussion**

There are various theories concerning the influence of obesity on the natural development, diagnostics or progression after radical treatment of prostate cancer. The 5 times increased percentage of biochemical recurrence observed in Afro-Americans, compared to Euro-Americans, is sometimes explained by 3 times more frequent presence of overweight or obesity among the former (Spangler et al., 2007).

Its influence is definitely negative, including the following:


Some authors suggest another factor, namely, lower PSA concentration in obese patients (Baillargeon et al., 2005). The consequence of the aforesaid correlation may impact on prostate cancer diagnosis and evaluation of progression after its radical treatment. Other authors disclaim the abovementioned connection (Freedland et al., 2006).

The authors who prove that obese patients are characterized by lower PSA concentration, refer to the phenomenon of hemodilution. The supporters of that theory claim that obesity is characterized by a larger amount of circulating blood, so theoretically the constant PSA mass circulating in the organism would be dissolved in a large amount of plasma, resulting in a lower PSA concentration.

However, our research has not proved that the elevated BMI has a significant influence on the preoperative PSA concentration. In order to explain the inconsistency we will call upon racial differences between the analyzed groups. The following research has been done on a group of patients of Caucasian race, while the aforesaid research has been frequently based on ethnically heterogeneous groups. The cause of differences between the outcomes can result from the polymorphism of the androgen receptor which causes higher PSA concentration in Afro-Americans, as well as statistically significant bigger obesity of this group (Xu et al., 2002). The influence of ethnical differences can, of course, be dismissed by appropriate statistical manipulations, nevertheless, it seems that research done on homogenous groups is characterized by greater statistical power.

In order to exclude the potential influence of hemodilution on the PSA concentration, the PSA mass in each patient has been calculated. Thanks to mathematical formulas used to estimate the total amount of circulating blood, its amount can be quite precisely determined. It has to be underlined that the phenomenon of hemodilution in obese patients had no statistically significant influence on PSA concentration. Also, having excluded other factors influencing PSA concentration, such as: cancer differentiation in Gleason score, the extracapsular extension (pT3), positive surgical margins or the patient's age, no significant correlation between BMI and the preoperative PSA concentration has been found.

However, comparing both parameters (PSA concentration and the PSA mass) it has to be stressed that the probability of biochemical recurrence after RP is better predicted by PSA mass, which surely results from the fact that the PSA mass includes the element eliminating the phenomenon of hemodilution. Despite the fact that both preoperative parameters "equally well" evaluate the progression after RP, the PSA mass seems to be a little more sensitive parameter (which is indicated by the difference in the odds ratio and AUC).

#### **9.4 Conclusions**

30 Prostate Cancer – Diagnostic and Therapeutic Advances

The odds ratio of biochemical recurrence, with the PSA mass increased 10 times, is equal to 8,64 (95% CI: 2,54 – 29,3; p<0,001) (Fig. 4). The odds ratio of biochemical recurrence, with the

ROC curves for preoperative PSA mass and PSA concentration showed an area under curve (AUC) of 0,72 and 0,65 respectively for biochemical recurrence after RP (Fig. 5). The

Fig. 5. ROC curves for PSA mass as a preoperative predictor of biochemical recurrence after

There are various theories concerning the influence of obesity on the natural development, diagnostics or progression after radical treatment of prostate cancer. The 5 times increased percentage of biochemical recurrence observed in Afro-Americans, compared to Euro-Americans, is sometimes explained by 3 times more frequent presence of overweight or

2. dishormonose (Hsing et al., 2002; Kaaks et al., 2000) – abnormal hormone concentrations, which induces the intensification of diagnostics and at the same time

3. comorbidities, which pushes the prostate diagnostics into the background and

consequently patients suffer from more advanced forms of prostate cancer

RP (Area Under Curve - 0,72).

obesity among the former (Spangler et al., 2007).

postpones proper treatment,

Its influence is definitely negative, including the following:

1. difficulties in per rectum examination in obese patients (Bray, 2006),

**9.3 Discussion** 

PSA concentration increased 10 times, is equal to 7,66 (95% CI: 2,25 – 26; p<0,001).

difference between these two predictors (AUC) was statistically significant (p=0,04).

	- a. more frequent cancer diagnosis of pT3 prostate cancer,
	- b. more frequent diagnosis of metastases in the surrounding lymph nodes,
	- c. more frequent recognition of the positive surgical margin,
	- d. shorter cancer-specific survival time,
	- e. higher percentage of progression.

The Influence of Obesity on Prostate Cancer Diagnosis and Treatment 33

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**3** 

*1,2,4,5Canada 3Brazil* 

**Renewing Perspectives on Men's Prostate** 

Margareth Santos Zanchetta1, Margot Kaszap2, Marko Monteiro3,

*3State University of Campinas, Dept. of Science and Technology Policy, Campinas, SP 4Humber Institute of Technology and Advanced Learning, School of Health Sciences Nursing Program & University Health Network - Toronto General Hospital, Toronto, ON* 

In this chapter, we intend to familiarize readers with the complex scope of the experience of being a man with prostate cancer in current societies and dealing with scientific and popular health knowledge related to prostate cancer. We discuss issues of taking care of one's male body, being an older learner learning while facing a chronic degenerative disease, as well as the questions that social and health care professionals may encounter from men in providing meaningful health care. The provision of health care to men seems controversial, due to the lack of national policies on men's health in most countries as well as scarcity of

This chapter presents a brief overview of the state of knowledge about masculinities and gender, health literacy, and age – all major social determinants of health for men. The authors of each section present scientific knowledge produced in their qualitative research to contextualize other scholars' ideas and arguments. At the end of each section are clinical

**2. Men, masculinities, health and prostate cancer: Complex technology, body** 

In this section we address the issue of control that may coexist with other needs facing men, from prostate cancer detection through rehabilitation. Being in control relates to both the social enactments of masculinities and to how men understand current trends in health and technology. Control has been discussed as an important signifier of virility in different

men's health promotion programs in multicultural societies.

**control, and decision making** 

vignettes and reflection questions related to the contents of each section.

**1. Introduction** 

**Cancer Literacy and Engagement Along** 

**the Disease Continuum** 

Franklin Gorospe IV4 and Roger Pilon5 *1Ryerson University, Faculty of Community Services Daphne Cockwell School of Nursing, Toronto, ON 2University Laval, Faculty of Education, Quebec, QC* 

*5Laurentian University, School of Nursing, Sudbury, ON* 

