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Article of the week: Guideline of guidelines: prostate cancer screening

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The introduction is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

If you only have time to read one article this week, it should be this one.

Guideline of guidelines: prostate cancer screening

Stacy Loeb
Department of Urology and Population Health, New York University, New York, NY, USA

INTRODUCTION

Prostate cancer screening is one of the most controversial topics in urology [1]. On one hand, there is randomised data showing that PSA screening results in earlier stages at diagnosis, improved oncological outcomes after treatment, and lower prostate cancer mortality rates. However, the downsides include unnecessary biopsies due to false-positive PSA tests, over-diagnosis of some insignificant cancers, and potential side-effects from prostate biopsy and/or prostate cancer treatment. The ongoing controversy is highlighted by the divergent recommendations on screening from multiple professional organisations. The purpose of this article is to summarise the recent guidelines on prostate cancer screening from 2012 to present.

Guideline of Guidelines

Many of us have developed an addiction to sports this summer. The World Cup football in Brazil with its continuous party spirit, the lush green lawns of Wimbledon and then the Test series between India and England. Our Web Editor could not contain himself:

Amidst all the fun and excitement, three important pieces of news are highlighted here:
  1. I requested our Associate Editor Stacy Loeb, who has a strong background in statistical methodology and health services research, to launch a series entitled ‘Guideline of Guidelines’. Most busy urologists tell me that they often find the many different society guidelines confusing. So we decided to publish a critical summary, finishing up with a set of ‘key points’ that our readers can use in their day-to-day practices. And what better way to kick off than with our biggest controversy – screening for prostate cancer [1].
  1. At #BAUS14 we conducted a live audience poll on when (and if) we should go completely digital. Here are the results:
  1. Inflammatory responses to tumours are recognised as being as important as stage and grade in predicting outcomes of treatment. Our ‘Article of the Month’ is a large 12-year European series of radical surgery for upper tract TCC. Neutrophil–lymphocyte ratio appears to be an important biomarker, as values of >2.7 confer worse cancer-specific and overall survivals [2]. The ratio of total neutrophils:total lymphocytes is easy to calculate from a routine preoperative blood test. I hope that many of you will be able to counsel your patients with this clinically useful biomarker.

Prokar Dasgupta
Editor-in-Chief, BJUI
Guy’s Hospital, King’s College London, London, UK

References

SoMe Guidelines in Urology: #urojc August 2014 summary

The August 2014 twitter-based international urology journal club (#urojc) took an introspective look at the newly published European Association of Urology recommendations on the appropriate use of social media.

This month’s article hit close to home as a panel of international urologists (many who are active on Twitter and #urojc) attempted to bring social media (SoMe) to the general public of urologists with some basic guidelines on effective, safe and honest communication. The article described the various social networks frequently used by physicians, highlighted some benefits of SoMe involvement, and pointed out the possible risks of SoMe. Recommendation statements emphasized clear, confidentiality, refraining from self-promotion, limits on patient-physician interaction and caution in engaging in SoMe.

From the start, it was evident that this was not a fluff piece and there was discussion to be had:

 

@CBayneMD started it off with concern about the recommendation to keep personal and professional content separate. Many argued that adding something personal kept the communication more interesting and reminded readers that behind the online persona is a person.

 

Good arguments were made on both sides. Using different SoMe outlets for personal and professional posts may make it easier to keep it appropriate.

 

The guideline section on refraining from self-promotion was generally well accepted, though some clarification was called for.

 

Another criticism was of the group of EAU panelists chosen to write the guideline. An excellent choice was made to include the twitter handles of the guidelines authors in the byline.

 

Several of the authors are undoubtedly SoMe experts.

 

@wandering_gu, one of the authors, defended the decision to include authors with varied levels of SoMe experience.

A common twitter disclaimer, amongst physicians, “RT (retweets) are not E (endorsements)” may or may not be worth much.

…but may be necessary, nonetheless.

@Dr_RPM summarizes the message of this guideline document.

Whether or not you agree with the EAU SoMe guidelines or the previously published BJUI SoMe Guidelines, it’s clear that SoMe in medicine, and especially urology, is an important part of the future. We should all continue to be thoughtful in our involvement with SoMe and encourage our friends and colleagues to participate. Thank you all for another exciting discussion. Make sure to keep an eye on @iurojc and #urojc for next month’s International Urology Journal Club!

 

Parth K. Modi is a PGY-4 urology resident at Rutgers-RWJMS in New Brunswick, NJ. He has an interest in urologic oncology, robotics and bioethics and tweets @marthpodi.

 

Engaging responsibly with social media: the BJUI Guidelines

  • The final, peer-reviewed version of this paper has been accepted for publication in BJUI.
    You can find it here. Please cite this article as doi: 10.1111/bju.12788

    The social media revolution is well underway. Facebook, Twitter, YouTube, Instagram, Weibo, Blogger, LinkedIn, and many other social media platforms, have now penetrated deeply into our lives and have transformed the way in which we communicate and engage with society. The statistics are staggering. As of mid-2014, the total number of global users of the following platforms has exceeded billions of people from every nation in the world:

    • Facebook – over 1.3 billion users
    • Twitter – over 280 million active users
    • YouTube – over 1 billion people view YouTube each month
    • Instagram – over 200 million users
    • LinkedIn – over 270 million users

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Social media has also become very popular among-st healthcare professionals both on a personal and professional basis. The reach and engagement which social media enables, along with the incredible speed with which information is disseminated, clearly creates opportunities for advances in healthcare communication. However, because healthcare professionals also have serious professional responsibilities which extend to their communication with others, there are dangers lurking in social media due to the inherent lack of privacy and control.

As a result, major professional bodies have now issued guidance for their members regarding their behaviour using social media. These include bodies representing medical students, general practitioners, physicians, oncologists, the wider medical community, as well as major regulatory bodies such as the Federation of State Medical Boards and the General Medical Council (GMC) in the UK, whose role is to licence medical practitioners. The guidance from the latter, part of the GMC’s Good Medical Practice policy, has significant implications as failure to comply with this guidance could impact a doctor’s licence to practice. All health care providers engaging in social media need to familiarize themselves with the relevant institutional, local, and national guidelines and policies.

There are many examples of healthcare providers who have faced disciplinary action following content posted on social media platforms. For example, posting photos of a drunk patient to Instagram and Facebook [1] is likely to result in serious disciplinary and legal action. In another case, a doctor in the USA was dismissed from her hospital and censured by the State Medical Board when she posted online details of a trauma patient [2]. Although her posting did not reveal the patient’s name, enough information was posted for others in the community to identify the patient. Furthermore, a review of physician violations of online professionalism and disciplinary action taken by State Medical Boards in the USA demonstrated that this case was not isolated [3]. Over 90% of State Medical Boards reported that at least one of several online professionalism violations had been reported to each of them. The most common violations were inappropriate patient communication online, often of a sexual nature. While the most frequent plaintiffs were patients and their families, it is noteworthy that complaints by other physicians were reported in half of State Medical Boards. Overall, serious disciplinary action including licence restriction, suspension or revocation occurred in over half of cases. There is clearly a need for healthcare professionals to be aware of their responsibility when communicating online.

So what of urology and social media? There is no doubt that many urologists have embraced social media with great enthusiasm, and urology has been one of the specialties leading the way [4-7]. The BJUI has been at the forefront of this enthusiasm as we have implemented a wide-ranging and evolving social media strategy including an active presence on the main social media platforms, a popular blog site, and a strategy to integrate our journal content across these platforms [8]. We now also recognise achievements in social media in urology through our annual Social Media Awards and by introducing a formal teaching course at the 2013 British Association of Urological Surgeons (BAUS) Annual Meeting, the first such course at a major urology meeting. While continuing to encourage the development of social media in urology as one of our key strategies, we also recognise that there are risks inherent in engaging in social media and that clinicians must be aware of these risks.

We therefore propose the following guidelines for healthcare professionals to ensure responsible engagement with social media. Much of this content is in alignment with advice issued by the other bodies listed above.

 

  1. Always consider that your content will exist forever and be available to everyone. Although some social media platforms have privacy settings, these are not foolproof and one should never presume that a post on a social media platform will remain private. It should instead be assumed that all social media platforms lack privacy and that content will exist forever.
  2. If you are posting as a doctor, you should identify yourself. The GMC guidance has specifically commented on anonymity. They advise that if you are identifying yourself as a doctor then you should also give your name, as a certain level of trust is given to advice from a doctor. People posting anonymously should be very careful in this regard as content could always be traced back to its origins, particularly if it became a matter for complaint.
  3. State that your views are your own if your institutions are identifiable. It is commonplace for clinicians to identify their institutional affiliation in their social media profile. While not an excuse for unprofessional activity, it is good practice to state that your views are your own, particularly if you occupy leadership positions within that institution.
  4. Your digital profile and behaviour online must align with the standards of your profession. Whatever standards are expected of the licencing body for your profession must be upheld in all communications online. You should also be aware that what you post, even in a perceived personal environment such as Facebook, is potentially accessible by your employers. As employers they will have a certain standard of behaviour that they expect. For example, use of inappropriate language or images of drunkenness could result in disciplinary action.
  5. Avoid impropriety – always disclose potential conflicts of interest. The American Society of Clinical Oncology (ASCO) includes this important point in their guidance. Influencers in social media can hold powerful sway and clinicians have a responsibility to use this influence responsibly and manage any potential conflicts.
  6. Maintain a professional boundary between you and your patient. It is not unusual for patients to be interested in their doctor’s social network. While most people do not restrict their Twitter and instagram followers for public profiles (and therefore all tweets must uphold professional standards), it is reasonable to politely decline a friend request on Facebook by stating that you keep your personal and professional social networks separate. The BMA guidance specifically advises against patients and doctors becoming friends on Facebook and advises that they politely refuse giving the reasons why.
  7. Do not post content in anger and always be respectful. It is considered inappropriate to post personal or derogatory comments about patients OR colleagues in public. Defamation law could apply to any comment made in the public domain.
  8. Protect patient privacy and confidentially at all times. There is an ethical and legal duty to protect patient confidentiality at all times, and this equally applies to online communication including social media. If posting a video or image, consent needs to be obtained for this even if the patient is not directly identifiable. Content within a post or image, including its date and location and your own identity, may indirectly identify a patient to others. The GMC guidance also states that you must not ‘discuss individual patients or their care with those patients or anyone else’. Thus posting about a case you have just seen could be in breach of these recommendations.
  9. Alert colleagues if you feel they have posted content which may be deemed inappropriate for a doctor. Quite unintentionally, colleagues may post content which may be regarded as unprofessional for any of the reasons listed above. Although a digital shadow may always persist, deleting the online content before it becomes more widely disseminated may help mitigate the damage.
  10. Always be truthful and strive for accuracy. All online content in social media should be considered permanent. It should also be considered that anyone in the world could potentially access this content. Therefore, truthfulness and accuracy are simple standards which should be upheld as much as possible.

Social media is a very exciting area of digital communication and is full of opportunities for clinicians to engage, to educate and to be educated. However, risks exist and an understanding of the boundaries of professional responsibility is required to avoid potential problems. Adherence to simple guidelines such as those proposed here may help clinicians achieve these aims.

Declan G Murphy1-2, Stacy Loeb3, Marnique Y Basto1, Benjamin Challacombe4, Quoc-Dien Trinh5, Mike Leveridge6, Todd Morgan7, Prokar Dasgupta4, Matthew Bultitude4

1University of Melbourne, Peter MacCallum Cancer Centre, Melbourne, Australia, 2Epworth Prostate Centre, Epworth Healthcare Richmond, Melbourne, Australia, 3New York University, USA, 4Guy’s Hospital, King’s College London, UK, 5Division of Urologic Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA, 6Department of Urology, Queen’s University, Kingston, ON, Canada, 7Department of Urology, University of Michigan, Ann Arbor, MI, USA

References

  1. ABC News. Chicago doctor allegedly posted photos of drunk patient on social media. Available at: https://jobs.aol.com/articles/2013/08/21/chicago-doctor-drunk-patient-photos-facebook/
  2. Above the Law. ER doc forgets patient info is private, gets fired for facebook overshare. Available at: https://abovethelaw.com/2011/04/er-doc-forgets-patient-info-is-private-gets-fired-for-facebook-overshare/.
  3. Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA 2012; 307: 1141-1142.
  4. Prabhu V, Lee T, Loeb S et al. Twitter Response to the United States Preventive Services Task Force Recommendations against Screening with Prostate Specific Antigen. BJU Int 2014; doi: 10.1111/bju.12748
  5. Loeb S, Catto J, Kutikov A. Social media offers unprecedented opportunities for vibrant exchange of professional ideas across continents. Eur Urol 2014; doi: 10.1016/j.eururo.2014.02.048
  6. Loeb S, Bayne CE, Frey C, et al. Use of social media in urology: data from the American Urological Association. BJU Int 2013; doi: 10.1111/bju.12586
  7. Matta R, Doiron C, Leveridge MJ. The dramatic rise of social media in urology: trends in Twitter use at the American and Canadian Urological Association Annual Meetings in 2012 and 2013. J Urol 2014; doi: 10.1016/j.juro.2014.02.043
  8. Murphy DG, Basto M. Social media @BJUIjournal – what a start! BJU Int 2013; 111: 1007-1009

The final, peer-reviewed version of this paper has now been accepted for publication in BJUI. You can find it here. Please cite this article as doi: 10.1111/bju.12788

 

Article of the Month: The Melbourne Consensus Statement

Every month the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, we feature a video from Tony Costello and Declan Murphy discussing the Melbourne Statement.

If you only have time to read one article this month, it should be this one.

The Melbourne Consensus Statement on the early detection of prostate cancer

Declan G. Murphy1,2,3, Thomas Ahlering4, William J. Catalona5, Helen Crowe2,3, Jane Crowe3, Noel Clarke10, Matthew Cooperberg6, David Gillatt11, Martin Gleave12, Stacy Loeb7, Monique Roobol14, Oliver Sartor8, Tom Pickles13, Addie Wootten3, Patrick C. Walsh9 and Anthony J. Costello2,3

1Peter MacCallum Cancer Centre, 2Royal Melbourne Hospital, University of Melbourne, 3Epworth Prostate Centre, Australian Prostate Cancer Research Centre, Epworth Healthcare Richmond, Melbourne, Vic., Australia, 4School of Medicine, University of California, Irvine, 5Northwestern University Feinberg School of Medicine, Chicago, IL, 6Helen Diller Family Comprehensive Cancer Centre, University of California, San Francisco, 7New York University, 8Tulane University School of Medicine, Tulane, 9The James Buchanan Brady Urological Institute, Johns Hopkins University, USA, 10The Christie Hospital, Manchester University, Manchester, 11Bristol Urological Institute, University of Bristol, Bristol, UK, 12The Vancouver Prostate Centre, 13BC Cancer Agency, University of British Columbia, Vancouver, Canada, and 14Erasmus University Medical Centre, Rotterdam, The Netherlands

Read the full article

• Various conflicting guidelines and recommendations about prostate cancer screening and early detection have left both clinicians and their patients quite confused. At the Prostate Cancer World Congress held in Melbourne in August 2013, a multidisciplinary group of the world’s leading experts in this area gathered together and generated this set of consensus statements to bring some clarity to this confusion.

• The five consensus statements provide clear guidance for clinicians counselling their patients about the early detection of prostate cancer.

 

Read Previous Articles of the Week

 

Video: Why the Melbourne Statement?

The Melbourne Consensus Statement on the early detection of prostate cancer

Declan G. Murphy1,2,3, Thomas Ahlering4, William J. Catalona5, Helen Crowe2,3, Jane Crowe3, Noel Clarke10, Matthew Cooperberg6, David Gillatt11, Martin Gleave12, Stacy Loeb7, Monique Roobol14, Oliver Sartor8, Tom Pickles13, Addie Wootten3, Patrick C. Walsh9 and Anthony J. Costello2,3

1Peter MacCallum Cancer Centre, 2Royal Melbourne Hospital, University of Melbourne, 3Epworth Prostate Centre, Australian Prostate Cancer Research Centre, Epworth Healthcare Richmond, Melbourne, Vic., Australia, 4School of Medicine, University of California, Irvine, 5Northwestern University Feinberg School of Medicine, Chicago, IL, 6Helen Diller Family Comprehensive Cancer Centre, University of California, San Francisco, 7New York University, 8Tulane University School of Medicine, Tulane, 9The James Buchanan Brady Urological Institute, Johns Hopkins University, USA, 10The Christie Hospital, Manchester University, Manchester, 11Bristol Urological Institute, University of Bristol, Bristol, UK, 12The Vancouver Prostate Centre, 13BC Cancer Agency, University of British Columbia, Vancouver, Canada, and 14Erasmus University Medical Centre, Rotterdam, The Netherlands

Read the full article

• Various conflicting guidelines and recommendations about prostate cancer screening and early detection have left both clinicians and their patients quite confused. At the Prostate Cancer World Congress held in Melbourne in August 2013, a multidisciplinary group of the world’s leading experts in this area gathered together and generated this set of consensus statements to bring some clarity to this confusion.

• The five consensus statements provide clear guidance for clinicians counselling their patients about the early detection of prostate cancer.

 

Urologists up in arms? ….Diclofenac no longer indicated in high risk groups

This blog is an update form the originally published comment article in BJU International, 110: 607608.
DOI: 10.1111/j.1464-410X.2012.11330.x

On the 23rd June 2013 the MHRA (The Medicines and Healthcare products Regulatory Agency) issued a press release stating that ‘patients with serious underlying heart conditions, such as heart failure, heart disease, circulatory problems or a previous heart attack or stroke should no longer use diclofenac’. The MHRA is responsible for regulating all medicines and medical devices in the United Kingdom (UK) by ensuring they work and are acceptably safe.

 

 

The new guidelines in the UK state:

  • Diclofenac is now contraindicated in patients with established:
     ischaemic heart disease
     peripheral arterial disease
     cerebrovascular disease
    – congestive heart failure (New York Heart Association [NYHA] classification II–IV)

Patients with these conditions should be switched to an alternative treatment at their next routine appointment

  • Diclofenac treatment should only be initiated after careful consideration for patients with significant risk factors for cardiovascular events (e.g., hypertension, hyperlipidaemia, diabetes mellitus, smoking).

Now for urologists in the UK this has wider implications. What else are we to use for acute renal colic, chronic pelvic pain, prostatitis, urethritis and any other type of..-itis?

We are treating an ever aging population and the use of non-steroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, will increase. NSAIDs have been the cornerstone of pain relief in patients with first presentation of renal and ureteric lithiasis. The British Association of Urological Surgeons (BAUS) and the European Association of Urology (EAU) guidelines for the acute management of renal and ureteric lithiasis state the first line analgesia is an NSAID e.g. diclofenac [1][2]. There have been a number of clinical trials which have clearly shown that NSAIDs provide effective relief in patients who have acute stone colic [3][4][5].

Controversies of NSAID use

Rofecoxib (trade name Vioxx ®), was approved by the Food and Drug Administration (FDA) in May 1999. The drug was heavily promoted by the global pharmaceutical and chemical company Merck as safer than older generation NSAIDs. The increased risk of stroke was highlighted in a large study, the Vioxx gastrointestinal outcomes research (VIGOR) study, published in the New England Journal of Medicine in 2000. Merck voluntarily took rofecoxib off of the market on 30 September 2004 after research showed that it almost doubled the risk of myocardial infarction and stroke when taken for 18 months or longer. In 2007 Merck paid $4.85bn to settle about 26 000 lawsuits in the United States relating to the drug in state and federal courts.

What are the alternatives suggested?

Naproxen and low-dose ibuprofen are considered to have the most favourable thrombotic cardiovascular safety profiles of all non-selective NSAIDs. There is limited evidence for the use of naproxen and low-dose ibuprofen in the management of acute renal colic. We do not know if the efficacy is equivalent to diclofenac. There are a lot of unanswered questions since the press release, but the key questions remain: Is this guidance applicable to us as urologists? And will this change my practice?

This topic is an important area for urologists to be aware of as NSAIDs are prescribed daily in urological practise to a wide range of patients. There is some caution that has to be exercised when reviewing the published data. In a recently published meta-analysis by the Coxib and traditional NSAID Trialists’ (CNT) Collaboration group their data provides further evidence that the vascular risks of high-dose diclofenac, and possibly ibuprofen, are comparable to coxibs.

The majority of trials evaluating the cardiovascular risk of NSAIDs have looked at a group of patients with predominately arthritis or Alzheimer’s disease; not a typical urological cohort of patients. None of the studies in the meta-analysis looked at the short term use of NSAIDs, in particular diclofenac. Some may argue that absolute rates of events were low and clinically irrelevant as the event rates in the included trials are considerably lower than in routine clinical settings.

The options for the treatment of acute urological pain have not changed in the past 15 years. COX-2 selective inhibitors and diclofenac are associated with an increased risk of thrombotic events. Naproxen is associated with a lower thrombotic risk and low doses of ibuprofen (1.2 g daily or less) have not been associated with an increased risk of myocardial infarction. The lowest effective dose of NSAIDs should be prescribed for the shortest period of time to control the symptoms and the need for long term treatment should be reviewed periodically. As we treat an ever aging population with increasing medical co-morbidities the widespread use of NSAIDs has to be evaluated and urologists need to keep up to date with current prescribing guidelines and long term cardiovascular risk factors. 

 

Jonathan Makanjuola is a Urology Trainee, Innovator and techie based at King’s College Hospital, London, United Kingdom. @jonmakUrology

References

  1. EAU guidelines on urolithasis. European Association of Urology; 2011. https://www.uroweb.org/gls/pdf/18_Urolithiasis.pdf. Accessed 12 December 2011.
  2. Guidelines for acute management of first presentation of renal/ ureteric lithiasis (excluding pregnancy). British Association of Urological Surgeons; 2008. https://www.baus.org.uk/AboutBAUS/publications/stones-guidelines. Accessed 12 December 2011.
  3. Phillips E, Kieley S, Johnson EB, et al. Emergency room management of ureteral calculi: current practices. J Endourol 2009; 23: 1021–1024.
  4. Micali S, Grande M, Sighinolfi MC, et al. Medical therapy of urolithiasis. J Endourol 2006; 20: 841847.
  5. Engeler DS, Schmid S, Schmid HP. The ideal analgesic treatment for acute renal colic–theory and practice. Scand J Urol Nephrol 2008; 42: 137–142.

 

 

Comments on this blog are now closed.

 

 

Article of the week: Dutch GPs influenced by ERSPC PSA study

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video of Miss van der Meer and Dr Blanker discussing their article.

If you only have time to read one article this week, it should be this one.

Impact of the European Randomized Study of Screening for Prostate Cancer (ERSPC) on prostate-specific antigen (PSA) testing by Dutch general practitioners

Saskia Van der Meer, Boudewijn J. Kollen*, Willem H. Hirdes, Martijn G. Steffens, Josette E.H.M. Hoekstra-Weebers, Rien M. Nijman and Marco H. Blanker*

Department of Urology, Isala Clinics, Zwolle, and Departments of *General Practice, Psychosocial services and Urology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands

Read the full article

OBJECTIVE

• To determine the impact of the European Randomized Study of Screening for Prostate Cancer (ERSPC) publication in 2009 on prostate-specific antigen (PSA) level testing by Dutch general practitioners (GPs) in men aged ≥40 years.

MATERIALS AND METHODS

• Retrospective study with a Dutch insurance company database (containing PSA test claims) and a large district hospital-laboratory database (containing PSA-test results).

• The difference in primary PSA-testing rate as well as follow-up testing before and after the ERSPC was tested using the chi-square test with statistical significance at P < 0.05.

RESULTS

• Decline in PSA tests 4 months after ERSPC publication, especially for men aged ≥60 years.

• Primary testing as well as follow-up testing decreased, both for PSA levels of <4 ng/mL as well as for PSA levels of 4–10 ng/mL.

• Follow-up testing after a PSA level result of >10 ng/mL moderately increased (P = 0.171).

• Referral to a urologist after a PSA level result of >4 ng/mL decreased slightly after the ERSPC publication (P = 0.044).

CONCLUSIONS

• After the ERSPC publication primary PSA testing as well as follow-up testing decreased.

• Follow-up testing seemed not to be adequate after an abnormal PSA result. The reasons for this remain unclear.

 

Read Previous Articles of the Week

 

Editorial: Impact of ERSPC study on PSA testing in the Netherlands

General practitioner (GP)’s view on screening for prostate cancer in the Netherlands: the impact of a randomized trial

I am grateful to be given the opportunity to provide an editorial comment on a so-far unique publication investigating the impact of results of the European Randomized study of Screening for Prostate Cancer (ERSPC) on the attitude of Dutch GPs in requesting a serum determination of PSA in men aged >40 years. Access to data from one of the major health insurance companies and the structure and data acquisition of regional laboratories in the Netherlands provided an opportunity to carry out the project. This included the differentiation of age groups, of primary as opposed to repeat PSA testing and, in the case of the hospital database, of repeat PSA testing within 1 year, which provided the opportunity to address the primary goal of the study: the evaluation of the difference in primary PSA testing rates as well as follow-up testing before and after the 2009 publication of interim data from the ERSPC study. The fact that a Dutch translation of this publication and a recommendation by the Dutch Association of General Practitioners (Nederlands Huisartsen Genootschap, NHG) were mailed at the same time and the fact that GP guidelines had not been changed since 2005 in the Netherlands provided an important basis for the reported study.

Two different databases were used and PSA testing was evaluated 1 year before and 1 year after March 2009 (excluding the month March 2009). An overview of the data acquisition and results is given in Table 1. In brief, the data based on insurance claims show a significant decrease in PSA use before and after the 2009 publication. This decrease was less pronounced or not seen at all in men aged 70–80 or >80 years. The study selectively identified men in the ERSPC region of Rotterdam after exclusion of those assigned for re-testing in the screening arm. In line with earlier investigations, the PSA testing rate in the Rotterdam region was considerably higher then in the rest of the Netherlands. This effect was blamed on increased awareness and possibly on the motivation of men randomized into the control group of the study. The so-called ‘hospital database’ refers to a regional GP laboratory. It remains unexplained why only 2098 men of the total of 9766 men who were identified as having undergone primary PSA testing (Tables 1 and 2 in the study) were included in the analysis. These data show that there was no overall difference in testing before and after the ERSPC publication, but the proportion of re-testing decreased significantly between the two periods.

Table 1: Data acquisition and results.

Several comments can be made on this study. First, information provided on the insurance claims database allows an estimate of the proportion of men in whom PSA is evaluated (123 996/715 000 = 17.3%) and of those who undergo primary PSA testing for early diagnostic purposes (66 848/715 000 = 9.4%). The overall figure contrasts sharply with the results of a study by the Central Bureau of Statistics in the Netherlands, published in 2006. The study shows PSA use of 30–40% for the age groups 60–70 years or older.

Second, as the authors acknowledge, the differentiation between primary PSA tests for the purpose of early diagnosis and for other purposes may not be entirely reliable; however, the bias resulting from possibly incorrect assumptions is likely to be small.

Third, the sub-analysis of data coming from the Rotterdam region is likely to show the impact of greater awareness resulting from written informed consent before randomization and the effect of randomization into a control group. The data confirm an earlier evaluation of this subject (reference 7 in Van der Meer et al.) and at the same time provide a rough estimate of the level of contamination which may take place in the ERSPC study, Rotterdam region.

Fourth, it is interesting to see how age and previous PSA values influence the request for repeat PSA studies. It is counterintuitive (Table 3 in Van der Meer et al.) that even in the critical PSA range 4–10 ng/mL a significant decrease of PSA use within 1 year was seen. The multivariate analysis shows that study period before and after 2009, PSA categories and age groups are all significantly related to the decrease of PSA re-testing within 1 year.

Finally, as one of the initiators of the ERSPC study, I should like to refer to two important follow-up publications (Schröder et al.Heijnsdijk et al.) that point to the over-diagnosis and over-treatment of prostate cancer as the main reasons why the almost 30% reduction in prostate cancer mortality in screened men cannot (yet) be used for establishing population-based screening. For these reasons, the authors fully agree with the viewpoint of the Dutch GP Association and the recommendation against routine use of PSA-driven screening for prostate cancer; however, as pointed out in the last sentences of their paper instruments are now available to decrease over-diagnosis and the rate of unnecessary biopsies. In addition to that, it should be realized that men who are well informed and wish to be tested for prostate cancer cannot be refused PSA testing. To assist this process, the International Society of Urology (SIU) and the international movement ‘Movember’ have recently made available on their websites a validated decision aid for men who wish to be tested, their GPs and their treating urologists.

Fritz H. Schröder
Erasmus Medical Center, Rotterdam, The Netherlands.

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Video: PSA testing decreased in the Netherlands after ERSPC study

Impact of the European Randomized Study of Screening for Prostate Cancer (ERSPC) on prostate-specific antigen (PSA) testing by Dutch general practitioners

Saskia Van der Meer, Boudewijn J. Kollen*, Willem H. Hirdes, Martijn G. Steffens, Josette E.H.M. Hoekstra-Weebers, Rien M. Nijman and Marco H. Blanker*

Department of Urology, Isala Clinics, Zwolle, and Departments of *General Practice, Psychosocial services and Urology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands

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OBJECTIVE

• To determine the impact of the European Randomized Study of Screening for Prostate Cancer (ERSPC) publication in 2009 on prostate-specific antigen (PSA) level testing by Dutch general practitioners (GPs) in men aged ≥40 years.

MATERIALS AND METHODS

• Retrospective study with a Dutch insurance company database (containing PSA test claims) and a large district hospital-laboratory database (containing PSA-test results).

• The difference in primary PSA-testing rate as well as follow-up testing before and after the ERSPC was tested using the chi-square test with statistical significance at P < 0.05.

RESULTS

• Decline in PSA tests 4 months after ERSPC publication, especially for men aged ≥60 years.

• Primary testing as well as follow-up testing decreased, both for PSA levels of <4 ng/mL as well as for PSA levels of 4–10 ng/mL.

• Follow-up testing after a PSA level result of >10 ng/mL moderately increased (P = 0.171).

• Referral to a urologist after a PSA level result of >4 ng/mL decreased slightly after the ERSPC publication (P = 0.044).

CONCLUSIONS

• After the ERSPC publication primary PSA testing as well as follow-up testing decreased.

• Follow-up testing seemed not to be adequate after an abnormal PSA result. The reasons for this remain unclear.

 

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