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EAU 2016 Congress Days 1 & 2

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Willkommen in München! I’m happy to give you some flavours of this year’s return of the EAU meeting to my home country after nine years of absence. Let’s start of with the first little episode that many of us might have encountered: Arriving at the congress centre, it took me only 1 minute to recognize that the EAU is always racing ahead: They placed the famous red London telephone box right in the centre of the entry hall. What a start! It created the scenery of joyful anticipation of EAU 2017 in England. Congress attendees were invited to take funny pictures. Great idea to do that on the first day of the congress rather than after many days of work and party. Not surprisingly the BJUI Board jumped in and seized this opportunity.

EAU-1-1Ben Challacombe and Matthew Bultitude
posing for EAU 17 in London.

 

 

 

 

 

 

 

But let’s get back to the present and to Munich’s highlights on Friday. The congress kicked off with the joint meetings of the EAU and various urological societies from around the globe. The EAU has started to reach out to urologists from all countries over the couple of years – one factor on their way to being currently recognized as the world’s leading association in our specialty. The joint sessions covered a colourful range of topics from urological oncology over men’s health to functional and reconstructive urology. Highlight of the day though was of course the opening ceremony on Friday night. I gave my best shot for BJUI’s best #selfie award when asking three beautiful violin artists to smile for the camera. I wasn’t successful, but it was fun anyhow.

🙂 You’ll find out the best #selfie winner later.

EAU-1-2@HendrikBorgmann at Opening Ceremony with Violin Artists

 

 

 

 

 

Still, the selfie experience made the girls feel so confident that they gave the audience a virtuoso, charmful atmospheric violin performance. EAU Secretary General Prof. Chapple gave out 13 awards for great achievements by pioneers in our field. Prof. Artibani received the Willy Gregoir Medal, Prof. Teillac the Frans Debruyne Life Time Achievement Award and Prof. Briganti the EAU Crystal Matula Award. Yet, the greatest honour was given to an absolute luminary in urology: When Michael Marberger received the EAU Honorary Member Award, standing ovations from the audience and an open-hearted applause created a goose bump atmosphere. There’s nothing more to say.

EAU-1-3Michael Marberger receiving the EAU Honorary Member Award

 

 

 

 

 

 

 

Waking up on Saturday after Friday nights activities – paying for it, as usual – drove me into the first plenary session: Evidence-based medicine vs. common practice / challenging the evidence. EAU Guidelines office chair James N’Dow and European School of Urology chair Joan Palou led the discussion, which used clinical cases to stimulate the debate between two opposing camps: pro vs. con for medical-expulsive therapy and personal experience vs. EAU guidelines for male incontinence after radical prostatectomy. The first plenary was rounded up by the AUA lecture by Abraham Morgentaler on a 40 years perspective on testosterone therapy.

 

EAU-1-4Lively discussions on the current state of evidence for medical expulsive therapy during the first plenary session

Munich’s conference centre made me cover some distance and burn some calories when rushing to the poster sessions. Funnily or annoyingly, depending on the point of view, a lot of poster presenters were fighting with rigid poster walls and poor needles. On top of that, scientific exchange was limited during the 20 minutes of poster viewing preceding the talks – shall we dedicate more time to talks instead?

EAU-1-5Poster presenters struggling to pin their research on stiff walls.

 

The EAU congress wasn’t all about the latest research though. Of course, education played a major role, which was reflected by over 70 hands-on training courses. You want to improve your surgical skills on adrenalectomy? No problem. Try out Green Light Laser Vaporisation and get advice from experts? Go ahead. Looking for advanced training on urethral stricture surgery? Sure! There were hands-on-training sessions for everybody.

EAU-1-6Practice, practice, practice. Trainers and trainees enjoying surgical simulation during hands-on-training course.

The congress wouldn’t have been the same without it’s indispensable elixir of life: LIVE SURGERY. The Urotechnology, Robotic Urology and Urolithiasis Sections shined with their latest advancements: 3D-HD laparoscopy, fluorescence partial nephrectomy, SPIES-assisted and NBI-assisted ureterorenoscopy for upper tract urothelial cancer – the spectacle went on and on. Interestingly, a working group from Italy took on the hot topic of ethics in live surgery for an important study: In their work “Live surgery: Harmful or helpful? Experience of the ‘Challenge in Laparoscopy and Robotics’ meeting” the authors retrospectively reviewed 197 live surgery cases. The authors found an acceptable overall complication rate of 11.6% according to Clavien Dindo classification. Over the course of time, the interest in live surgery seemed to remain alive, as shown by the high number of 539 participants per event. I think the study is very original and we can anticipate an interesting paper on this very soon.

Sunday morning was all about the Plenary Session on prostate cancer in the eURO Auditorium. Results of the TOOKAD® Phase III trial were highly anticipated. High noon was at 8AM when Marc Emberton presented the results of their study “TOOKAD Soluble ® versus active surveillance in men with low risk prostate cancer – a randomized phase 3 clinical trial”. 413 patients were randomized 1:1 to vascular-targeted photodynamic (VTP) therapy vs. active surveillance. Progression free survival rates were higher for VTP (28% of patients progressed) when compared to active surveillance (58% progressed; hazard ratio: 0.34; 95% confidence interval: 0.24-0.46; p<0.001). Also, fewer VTP treated men underwent radical therapy within 24-months: 6% vs. 29%, RR=0.20 [0.11-0.36].

EAU-1-7Results from the TOOKAD study

Discussant Declan Murphy congratulated the group for the well-designed study and asked 3 questions:

1.) Does this type of very low-risk prostate cancer need intervention?

2.) What is going on in the control arm?

3.) What is the impact of TOOKAD on future intervention?

The population from the PRIAS study was comparable to the presented study population. PRIAS showed that active surveillance can be pursued safely in very low-risk prostate cancer patients. Moreover, the control arm of the TOOKAD study had much worse outcomes for histological progression, negative biopsy and need for radical intervention when compared to the PRIAS population. Finally, salvage radical prostatectomy post-TOOKAD had notable morbidity and disappointing oncological outcomes in a small study of 19 patients, which differs from outcomes observed for radical prostatectomy after active surveillance.

 

EAU-1-8Take home messages from discussant Declan Murphy

After this strong opening, the prostate cancer fireworks continued with debates on the role for pre-biopsy MRI, timing of radiotherapy after radical prostatectomy and indications for chemotherapy in hormone-naïve prostate cancer.

On Sunday afternoon magic happened: the #EAU16 Twitter feed took the 10,000-tweet-hurdle for the first time in #EAU Twitter history: Congratulations and thanks to all contributors. More numbers needed? Up to 15 million impressions, 1,400 users and 115 tweets/hour show that the Twitter fan community is constantly growing. No one of us knows when the boom will slow down.

EAU-1-9Urologic Twitterati contributing to the #EAU16 Twitter feed.

 

Which content went viral though? See for yourself in the wordle I pulled from Tweetarchivist and the Retweet analysis from Twitonomy.

EAU-1-10Wordle showing the top words used in the #EAU16 Twitter feed.

 

EAU-1-11Most retweeted tweets during #EAU16.

 

Despite that, the social media highlight was yet to come: the famous BJUI SoMe awards! The urologic Twitterati gathered in the beautiful roof-top lounge in Munich city centre for the “cult awards” as Prokar Dasgupta (@prokarurol), BJUI Editor-in-chief, justifiably stated. We warmed up with wine or beer and felt the suspense increasing when everybody was waiting for Declan’s last-minute slide editing to the start the show. Prokar honoured the Twitter community for their huge engagement. While everybody was enjoying the show, we were coming closer to the most awaited prize: the @BJUIjournal best selfie award! Morgan Roupret (@MRoupret) and Angelika Cebulla (@AngelikaCebulla) were fighting hard for it, but it the end Maria Ribal (MariaJRibal) raced ahead and won the coveted award. But the show wasn’t over and the best was still to come in the final round: the @BJUIjournal Social Media Award 2016. Stacy Loeb (@LoebStacy) made a great proof-of-principle when initiating the #ILookLikeAUrologist campaign, which reached close to 1,000 tweets and was the well deserved award winner.

EAU-1-12Stacy Loeb receiving the prestigious BJUI Social Media Award 2016 from Prokar Dasgupta and Declan Murphy

For more details of the Award winners look out for Declan’s forthcoming blog, coming to this site soon.

Congratulations to all social media entrepreneurs! Stay tuned for EAU congress days 3 and 4! Peace, love and #urology!

 

Hendrik Borgmann, Urologist, Mainz/Vancouver
@HendrikBorgmann

 

 

Rehumanising

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james-duthieWe live in a dehumanizing world. Out of a need for efficiency, convenience, and reassurance, we both dehumanize and are dehumanized routinely in our commerce and relationships. We are not a three-dimensional human being of unique genetics and experience, forte and frailty, preferences and peculiarities to our bank, public library, or insurance company. Out of necessity, these structures diminish us to a number or barcode. We are grouped by age and demographic, measured by our internet clicks, targeted according to our income by corporations.  To those profiting from our consumption our individuality is irrelevant; the big money is in exploiting groups. Whether you support a free Tibet does not concern the people selling cheeseburgers, unless enough people agree with you that some marketing leverage can be generated from this fact. In medical research we reduce people to “female between 40 and 75 years with chemotherapy naïve metastatic ovarian carcinoma”. Not “Julie, mother of three boys (one with cerebral palsy), who put up with her vague abdominal symptoms for too long because she was preoccupied by supporting her younger sister out of an abusive relationship”.  While logistical limitations do not allow for the statisticians to enter into every individual story, we reassure ourselves that the depersonalized and homogenized data from these studies is for the greater good. Indeed, sometimes it just isn’t any of our business.

We can accept that on this macro level there are faceless amoral corporations that care only about how to alter our spending patterns, but on an interpersonal level we can be equally guilty of dehumanizing attitudes. Thanks to the heuristics developed by our ancestors, which I for one am grateful for, the human brain is very efficient at mentally grouping things under such headings as “dangerous” and “delicious”. This has allowed our continued survival. Having a general suspicion of things that looks like snakes means a reduced risk of envenomation. Being suspicious of strangers by default means that we are less likely to be on the back foot if someone pulls a spear on us. It would be nice to think that we have largely put this simplistic cognitive process behind us, but we tend to fall back on bad habits. Every time we mentally label a person we are trimming their humanity in order to fit them into a pre-existing cognitive category. When we think “young hoodlum”, “old codger”, “drug addict”, “liberal”, or “health nut”, we are in fact extracting what we deem to be the most salient point of person and making it the sum total of their identity. There is obviously expedient for us, as we continue to do it. It makes it easier to ignore the “derelict” on the street, and not feel too bad about the “foreigners” affected by natural disasters. Our bias is routinely exploited by our leaders, especially in times of war. We are not killing  people very similar to ourselves, we are fighting “scum”, “heretics”, “commies”. While studying for a degree in psychology I came across a study that demonstrated that people attribute more negative characteristics to people groups if they are referred to by nouns rather than adjectives. People were more mistrustful of others described as “Poles” or “Jews”, rather than “Polish” or “Jewish”. The objective label nudges people into a category, with the adjective reminds us that these are complex individuals, who happen to have a given ethnicity or faith.

We have a reflexive discomfort at being dehumanized ourselves. We don’t like being treated like cattle by airlines or sports stadiums. We despise being written off as nothing more than the town we came from, the school we went to, the era we grew up in, or our gender. We know from personal experience that we are unique, and attribute value to this, at least in ourselves.

Surgery is dehumanizing. We take frightened people, anaesthetize them so that they cannot resist, and then disassemble them. The intention is to reassemble them in an improved way, but we are reducing people to a collection of organs and meat in a way that strips them of usual dignity. Until the Renaissance, disassembling the dead was considered too shameful to tolerate. Indeed, to begin with only executed criminals, considered sub-human (already dehumanized), were considered suitable candidates for anatomical dissection.  It was too much to imagine a person opened up for the world to see their insides, their dignity stripped in an extreme form of nudity. I have already written about how not entering into the full experience of every human drama is what makes surgery a viable career (https://www.bjuinternational.com/bjui-blog/surgery-is-not-normal/), and I don’t think it is helpful to focus on the bigger picture beyond the operating theatre while focusing on the technical steps of an operation, but a few points are worth considering.

Firstly, those of us who have had human dissection as a part of our training tend to share a common experience. While in the thick of a dissection, occasionally rewarded with the discovery of a familiar structure, it is normal to forget that the prosection was once the residence of a functioning person. Typically it is the glimpse of a uniquely human feature; the face, feet, hands that triggers a moment of shock at what is going on. I still recall looking down to see that our cadaver had painted toenails. Instead of being a learning resource, it struck me that this woman had spent time days before her death, tending to her toenails fastidiously, unaware of what was to come. This placed her in a room in her home, at a time of day, perhaps before leaving to attend a social event. The full experience of her humanity was infinitely greater than the tutorial aid she had been reduced to. The strict procedures governing the use of human tissue made sense, lest we forget the gift of the donor.

One of the more moving experiences I have had in a hospital is watching Intensive Care nurses managing comatose patients. My observation is that these patients are treated more gently than necessary, and there is a constant one-way conversation from the nurses explaining that now, they are going to reposition the legs. They are going to brush teeth. They are adjusting the pillow. Calling the patient by their name, as their words fall on deaf ears. While logically this makes no difference to medical treatment, it protects the nurse from dehumanizing the patient, making them more than an oxygen trace on a screen.

Ultimately, the effort to re-humanize is what makes us fully human. The unconscious patient or cadaver is not affected by our attitude towards them, but we sacrifice our own humanity whenever we revert to applying broad heuristics to other people. A cat knows to be frightened of snakes, but it takes human intelligence and will to deliberately consider that a person is more than something to fear, ignore, or desire. It is an act of overcoming base instinct. When we apply the appropriate reverence for a person as we prepare them for surgery, care for them in their unconsciousness, our respectfully use their dead body to improve the treatment of future patients, we affirm our own humanity. It is more for us than for them.

 

Jim Duthie is a Urological Surgeon/Robotic Surgeon. Interested in Human Factors Engineering, training & error, and making people better through electronic means. Tauranga, New Zealand. @Jamesduthie1

 

STAMPEDE at the Dumball rally

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20160110_092926_smI’m sure I’m not the only one to board a long haul flight with the aim of catching up on a little CPD reading, only to be led astray by a series of films that later I’ll never admit to watching. Still they can be educational, as having stopped studying History at the age of 12 I’m ashamed to admit that without this educational medium I would never have been aware that the 16th President of the United States spent his formative years hunting Vampires. So in January 2016 I boarded a 10-hour flight from London to Chennai equipped with the latest publication from the STAMPEDE Study, a Workshop Manual for the Hindustan Ambassador, and a sense of inevitability that I’d be watching Matt Damon land on Mars before we’d finished crossing Kent. Taking a car manual for in-flight entertainment was not a cunning plan to encourage my neighbouring passengers to change seats before I engaged them in conversation. I have an unread copy of Donald Trump’s 2009 tome “Think Like a Champion” that fulfils that role perfectly. The manual was my homework, as I was en route to join the Dumball Rally.

The Dumball Rally is a fancy-dress charity banger rally – that raises money for the Teenage Cancer Trust. Since its inception in 2006 (Amsterdam to Athens) it has raised over £650,000. This year the route was Chennai to Goa, via Kanyakumari (the Southern Tip of India), the Western Ghats, Cochin, and for our team a stapes-shuddering Rock Bar in Mysore. 37 Hindustan Ambassadors awaited us on the start-line, their fully enclosed monocoque chassis based on the Morris Oxford Series III that last rolled off the production line in Cowley in 1959 – just in case you’re thinking I didn’t read the manual.

As a Clinical Oncologist I’m admit to being in one of the more geek-orientated specialities. Who needs a PDE5-inhibitor when a graph depicting a Bragg Peak excites you? So as I read about the history of Hindustan Motors, and the inner workings of my Ambassador, I was struck by the commonality of their significant anniversaries with those of my chosen profession. Hindustan Motors was founded in 1942, the year after Charles Huggins published his seminal paper on Prostate Cancer. The Morris Oxford Series III began production in 1956, the same year that Hertz and Li first described the successful use of cytotoxic chemotherapy (methotrexate) to treat a solid tumour (Choriocarcinoma). The production of the Hindustan Ambassador began in 1958, the year Rosalind Franklin died. The final version of the Ambassador (the Avigo) began production in 2004, the same year Tak327 was published demonstrating a survival advantage for Docetaxel and prednisone in metastatic castrate-resistant prostate cancer. Who said altitude and wine don’t mix well?

The rally began on 10th January 2016. Our team, dressed as Dick Dastardly and Muttley (wise outfit choices in greater than 30 degrees centigrade heat), were pitted against a range of other themed cars from a fire-engine (with wired-in power washer), a yellow-submarine (broadcasting “Beatles” songs), to the Jungle Book (which continuously grew with foliage collected from the roadside). The Rally results are summarised below, and compared with the results from the STAMPEDE Study (finally read on the return flight).

STAMPEDE is a study assessing the impact of intensifying initial treatment for locally advanced and metastatic prostate cancer. Its novel Multi-Arm Multi-Stage (MAMS) design may prove as important to future cancer care as the results generated by the study itself. Basically MAMs permits multiple different primary questions to be addressed simultaneously and sequentially over a far shorter time period, and with fewer subjects, than would be required to address the questions separately.

Median Overall Survival for the Standard of Care (SOC) arm of STAMPEDE was 71 months, which increased to 81 months with the addition of 6 cycles of Docetaxel Chemotherapy. There was no additional benefit with the use of Zoledronic acid (with or without Docetaxel). Looking at the subset with metastatic disease, Median Overall Survival increased from 45 months to 60 months with the addition of Docetaxel, demonstrating that this should now be standard of care in suitable patients with metastatic disease. Regarding the Median Overall Survival for the Dumball Rally, there were insufficient events (only 1 car had to be abandoned), and follow-up is too short (8 days) to report meaningful data.

Median Failure Free Survival (FFS) for the SOC arm of STAMPEDE was 20 months, which increased to 37 months with Docetaxel. The hazard ratios were similar for both metastatic and non-metastatic subsets. Again there was no additional benefit with the addition of Zolendronic acid. The median FFS for the Hindustan Ambassador was about 6 hours. The passenger seat and seat-belt broke in our car whilst exiting the car-park having just collected it; most cars over-heated daily (interestingly the electrics are located directly beneath the radiator overflow); one engine seized completely; and an axel broke on Dumball 1, the organiser’s car.

Grade 3 + adverse events reported within the first 6 months of the STAMPEDE Study increased from 17% in the SOC arm to 36% with the addition of Docetaxel. Despite this the chemotherapy was well tolerated, with most patients completing all 6 planned cycles with minimal changes in dose or scheduling. Regarding the Rally, ironically it coincided with India’s National Road Safety Week. Their slogan “Hurry leads to worry; Accident brings tears; Safety brings cheers” repeated Orwellian-style in my subconscious as we negotiated the Indian traffic. In India they drive on the left……and sometimes the right, the middle of the road, the pavement –in fact wherever they want! A gentle toot of the horn lets other road users know where they are, and it appears to be the driver’s responsibility to avoid anything in front of them – no matter how late it pulls out. But it works – and everything keeps moving with good humour and smiles. It wasn’t unusual to be horrendously cut-up, only for the “offending driver” to then stop, get out the car and come over for a friendly chat and a photo opportunity. As a result, there were minimal adverse events – other than putting on a few additional Kg in weight eating curry 3 times a day.

Work on next year’s Dumball Rally has already started – rumours are that it may involve Nepal. If anyone is interested in taking part, please look at their website: www.dumball.org

 

Simon Hughes is a Consultant Clinical Oncologist at Guy’s and St Thomas’, London

 

 

The Zika virus epidemic in the Americas

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In May 2015, Brazil reported for the first time home-grown cases of Zika virus, since that moment the cases have increased dramatically and the infection caused by this virus has been spreading quickly to 22 other countries in the Caribbean, South and Central America. The spread of Zika in South America has been developing rapidly, pushing the WHO to declare the Zika epidemic as a Public Health Emergency of International Concern in February of 2016.

Zika virus was isolated accidentally for the first time from rhesus macaques in 1947, in the area known as Zika forest, located in Uganda; later, researchers observed that the virus could infect humans, but human infections have remained confined to Africa and Asia with few cases reported, until now when thousands of cases have been reported in South American countries since 2015.

Zika is an emerging mosquito borne virus, closely related to other important human viruses transmitted by mosquitoes like Yellow Fever, Dengue, and West Nile virus. The virus has a positive single strain of RNA genome, and belongs to the Flavivirus family. It is transmitted through the infected female mosquito Aedes spp bite, the same vector as Yellow Fever, Dengue, and recently Chinkungunya in the Americas. Distinct species of Aedes mosquitoes are related with the transmission of the virus; however, Aedes aegypti is the most common vector associated with the infection in humans. These mosquitoes are found in many countries in the Americas, a fact that have been contributing to introduction and spread of the virus inside the continent. Additionally, researchers have reported sexual, blood transfusions, and perinatal transmission.

The symptoms of the Zika infections are pretty similar to other mosquito-borne diseases that are circulating in the same geographical areas such as Dengue and Chinkungunya. These diseases are characterized by fever, headache, arthralgia, myalgia, rash, and conjunctivitis, making it difficult to make a differential diagnosis. Epidemiological data showed that until December of 2015, between 440,000 and 1.3 million of Zika cases were reported in Brazil. Additionally, data obtained from Health Ministry of Brazil also reported a significantly increasing number of microcephaly cases in areas infested with Zika, suggesting a possible relation between Zika and microcephaly. Recently, The New England Journal of Medicine reported the identification of Zika virus in fetal brain tissue obtained from a 32 weeks of gestation fetus with serious signs of microcephaly that was aborted after his mother had symptoms related with Zika some weeks after, supporting the idea that Zika virus could be associated with the development of microcephaly in the fetus. Sexual transmission of Zika has also been reported, but the information about it remains confused. Nevertheless, Zika virus has been isolated from semen.

Other neurological symptoms like Guillain-Barré syndrome have been associated with Zika infections. Reports obtained from outbreaks of Zika in French Polynesia in 2013, and Brazil in 2015, showed an increasing number of Guillain-Barré cases probably associated with Zika.

According with the epidemiological data, Colombia is the country second most affected by the Zika virus. Reports from Instituto Nacional de Salud (INS) showed that until January of 2016, 27,454 cases of Zika have been reported, no official data about increasing cases of microcephaly or Guillain-Barré related with Zika infection were observed.

With the 2016 Olympic games due to be held in Rio de Janeiro in August, the World will be watching how Brazil and other South American countries manage the spread of Zika virus in the coming months.

 

Miguel Hernando Parra Avila, Bact. MSc. PhD.

Posición Post Doctoral

Grupo BCEM (bcem.uniandes.edu.co)

Departamento de Ciencias Biológicas

Universidad de los Andes

Bogotá, Colombia

 

What’s the Diagnosis?

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This patient presented with sudden onset severe right loin pain and tachycardia. There was no history of trauma. The images shown are non-contrast and arterial phase CT.

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New Gleason grading system: Statement from the Editors of six journals

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The International Society of Urologic Pathology (ISUP) has completed a consensus process to modify and clarify the Gleason scoring system for prostate cancers (1). Five grade groups have been defined with tumors of ISUP Grade Group 1 being the least aggressive and having the lowest likelihood of progression, whereas those of ISUP Grade Group 5 have the highest likelihood of early systemic spread. This new system provides clearer guidance for pathologists to classify cancers on the basis of gland morphology, and it aligns better with contemporary management including active surveillance.

The editors of the major uro-oncology journals believe this is a helpful change for clinicians, researchers, and patients alike and are eager to help this system establish itself in the reporting of pathologic grade. To that end we are now asking investigators to use the ISUP system in the reporting of prostate cancers in their publications. As the grade groups correspond largely with current Gleason scores 6, 3+4, 4+3, 8, 9 and 10, the translation should be relatively simple. Over the next one to two years, side-by-side reporting of old and new histology may temporarily be necessary. We do recognize that some institutional and national databases are not set up to make the translation and exceptions will be granted in these cases.

Anthony Zietman MD
International Journal of Radiation Oncology Biology Physics

Joseph Smith MD
Journal of Urology

Eric Klein MD
Urology

Michael Droller MD
Urologic Oncology

Prokar Dasgupta MSc MD FRCS
BJUI

James Catto MBChB PhD FRCS
European Urology

Reference

  1. Epstein JI, Egevad L, Amin MB et al. The 2014 International Society of Urological Pathology (ISUP) Consensus Conference of Gleason Grading of Prostatic Carcinoma. Am. J. Surg. Pathol. 2016, 40: 244-252.

 

 

 

Where we are with screening and risk prediction for prostate cancer in 2016

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March Editorial ImageThe rate of PSA-based screening over the last 35 years can be compared with driving your car from the Netherlands to Italy. It starts with a rather flat drive, perhaps a few hills in the Southern part of the Netherlands, which represents the rate of PSA screening in the late 1980s. Moving with high speed through Germany, one gradually climbs to higher altitudes, i.e. the rate of PSA testing in the 1990s. Then the high (but very difficult to drive) summits and beautiful valleys of Switzerland are there, representing PSA testing practices in the new millennium and the decline in metastatic disease and related mortality [1]. Finally, we descend to Italy’s Po valley, comparable to PSA testing rates, especially in the USA after the recommendations of the USA Preventive Services Task Force [2,3].
The question is what will we do next? Will we take a left turn and slowly disappear into the sea like Venice? That is, returning to a situation where one out of two or three men died from their prostate cancer? [4] Or will we stop our car, look behind, see the beautiful landscape and return taking the Gotthard road tunnel, avoiding spillage of petrol (i.e. unnecessary PSA testing and potentially harmful prostate biopsies) and go straight to the valleys of Switzerland?
The first option is obviously not the way to go. Unfortunately, the recommendation to stop the use of the PSA test as a screening tool is a direct consequence of the rapid and uncontrolled uptake of the test, often followed by a random biopsy resulting in over-diagnosis and subsequent overtreatment. However, there are ample tools available to turn this situation around and reduce the negative effects of prostate cancer screening [5,6].
An example of such an approach can be found in the publication of Poyet et al. [7] in this issue of BJUI. In this study, the investigators validated updated versions of two multivariate risk-prediction tools, i.e. prostate cancer risk calculators (RCs), in a cohort of 1996 men all biopsied (6-, 8- or 12-core random biopsy) on the basis of an elevated PSA level or abnormal DRE. The data showed that both RCs outperformed the PSA/ DRE-based strategy in reducing unnecessary testing, and in addition avoided over-diagnosis. As said, this approach is one of the many opportunities to reduce the negative aspects of PSA-based screening all summarised in the different guidelines [8]. Reading these guidelines, it soon becomes clear that it is known that repeatedly testing men with low PSA levels is useless. It is known that screening men with a limited life expectancy will only cause harm, and that simply repeating a prostate biopsy after a negative biopsy result (i.e. no prostate cancer detected) is not the way to go. And yet, this is what we see happening in daily clinical practice [9,10].
So, where are we with prostate cancer screening and risk prediction in 2016? We are in a situation that we know that we can reduce suffering and death from (metastatic) prostate cancer, with early detection and treatment, but that we have to selectively identify men that can actually benefit. The latter is realistic if we start to implement the knowledge we have acquired over recent decades.

 

Monique J. Roobol
Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands

 

References

 

1 Schroder FH, Hugosson J, Roobol MJ et al. Screening and prostate cancer mortality: results of the European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. Lancet 2014; 384: 2027–35

 

2 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: 120–34

 

3 Banerji JS, Wolff EM, Massman JD 3rd, Odem-Davis K, Porter CR, Corman JM. Prostate Needle Biopsy Outcomes in the Era of the U.S. Preventive Services Task Force Recommendation against Prostate Specific Antigen Based Screening. J Urol 2016; 195: 66–73

 

4 Hsing AW, Tsao L, Devesa SS. International trends and patterns of prostate cancer incidence and mortality. Int J Cancer 2000; 85: 60–7

 

5 Roobol MJ, Carlsson SV. Risk stratification in prostate cancer screening. Nat Rev Urol 2013; 10: 38–48

 

6 Emberton M. Doubling our precision of risk stratification in early prostate cancer: too good to be true? BJU Int 2016; 117: 8–9

 

7 Poyet C, Nieboer D, Bhindi B et al. Prostate cancer risk prediction using the novel versions of the European Randomised Study for Screening of Prostate Cancer (ERSPC) and Prostate Cancer Prevention Trial (PCPT) risk calculators: independent validation and comparison in a contemporary European cohort. BJU Int 2016; 117: 401–8

 

8 Loeb S. Guideline of guidelines: prostate cancer screening. BJU Int 2014; 114: 323–5

 

9 Nordstrom T, Aly M, Clements MS, Weibull CE , Adolfsson J, Gronberg H . Prostate-specific antigen (PSA) testing is prevalent and increasing in Stockholm County, Sweden, Despite no recommendations for PSA screening: results from a population-based study, 2003-2011. Eur Urol 2013; 63: 419–25

 

10 Drazer MW, Huo D, Eggener SE. National Prostate Cancer Screening Rates after the 2012 US Preventive Services Task Force recommendation discouraging prostate-specific antigen-based screening. J Clin Oncol 2015; 33: 2416– 23

 

Correction: The word “their” was added to this sentence to clarify its meaning: “That is, returning to a situation where one out of two or three men died from their prostate cancer? [4]”

 

 

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BJUI Knowledge – CPD on the move

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IMG_0531-Rob-Mills-2016-a2BJUI Knowledge is a new initiative for urologists, combining online CPD content together with a platform for recording CPD activity in one place. BJUI Knowledge, has been released this month to all BAUS members for a free trial period up until the end of June. It will be made available to all urologists later in 2016.

Once registered you will see we have already published around 60 CPD modules across 12 curriculum areas covering the breadth of urological practise. More modules will be added each month. We believe there will be something to enable all urologists to keep up to date. Some topics will be useful as a refresher and others may provide the opportunity for updating on contemporary issues. In times of appraisal and revalidation this venture provides both the opportunity to carry out CPD activity as well record and retrieve it as an annual report.

 

0592-video-image-v2The interactive e-learning modules have the accreditation of the Royal College of Surgeons of Edinburgh. The modules have been commissioned as manuscripts from authors with a genuine interest in the topic and then subjected to independent peer review. Each manuscript is converted into an online e-module with a standardised format including: learning objectives, knowledge checks, a final assessment and key learning points. Within the module, link is provided to the original manuscript as well as links to the abstracts for each reference in the manuscript.

0590-hotspot-imageWe will be adding to the modules available by 10-15 per month until we have created our full curriculum. Existing content will also be updated regularly to ensure it remains current. Access to the site may be by smart phone, tablet or desk top, and internet explorer 10 or equivalent is recommended for best functionality.

 

The e-learning content is optimised to be viewed on any kind of device, including a smartphone.

The CPD registration element allows:

1. Automatic registration of successfully completed BJUI Knowledge modules, although reflection (recommended for all CPD activity) may be added later.

2. Recording of other CPD activity under a variety of headings. (If we receive feedback that alternative headings are required we can add to the list available).

3. There is an app (accessed from the CPD page) which allows registration of CPD activity to your BJUI Knowledge account from your mobile phone while on the move. For example you may be visiting a department or at a meeting and take a photo which can be sent to your CPD account with details of the activity carried out.

4. At designated intervals, perhaps annually for appraisal, a complete record of CPD activity can easily be generated.

I would encourage you to use this exciting new resource and feed back to us with your comments to [email protected]

 

Rob Mills is the Editor of BJUI Knowledge

 

 

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