On Doctoring MEDLINE searches, with reference librarian comments, March 2000

The question was

what symptoms of prostate disease warrant a referral to a urologist?

1     exp Prostatic neoplasms/    results=15020   
2     exp Urology/    results= 1088   
3     1 and 2    results= 70   
4     limit 3 to (human and english language and yr=1995-2000)    results= 47   

Reference Librarian comments

Good job. Interesting question. This is actually a bit "tricky." You said prostatic disease, but Ovid probably lead you to prostatic neoplasms. I'll bet that some of your 47 references were relevant to you.

I think I'll try it too, but I'll do it a different way, intentionally...

Medline 1991 to January 2000

#
Search History
Results
1
exp *Prostatic diseases/pa,co,di,dt,ec,ra,ri,rt,su,th [Pathology, Complications, Diagnosis, Drug Therapy,
Economics, Radiography, Radionuclide Imaging, Radiotherapy, Surgery, Therapy]
11369
2
exp "Referral and consultation"/
9669
3
(refer or referral or referred).ti.
1794
4
1 and (2 or 3)
31
5
limit 4 to (human and english language)
27

<1>
AN 98420742
AU Snyder C. Schrammel PN. Griffiths CB. Griffiths RI.
IN Covance Health Economics and Outcomes Services Inc.,
Washington, DC, USA.
TI Prostate cancer screening in the workplace. Employer costs.
SO AAOHN Journal. 46(8):379-84, 1998 Aug.
LM Matthews-Fuller Health Sciences Library (MFHSL).
AB Recognition of the mortality and morbidity associated with
prostate cancer has resulted in employer based screening programs. This
retrospective cohort study identified the employer costs of prostate cancer
screening and referrals due to abnormal
test results. The subjects were 385 men enrolled in a workplace screening
program at a single employer between 1993 and 1995.
Screening consisted of digital rectal examination (DRE) annually for enrolled
employees aged 40 years and older, plus annual prostate
specific antigen (PSA) testing for those 50 and older,
and those 40 and older and
considered at high risk. Data related to the health care and
lost productivity costs of screening and
referrals for abnormal test results were collected
and analyzed. The total cost of screening was $44,355, or
approximately $56 per screening encounter (788 DREs; 437 PSAs). Abnormal
screening tests resulted in 52 referrals. Upon further
evaluation, 42% were found to have an enlargement, 29% a node,
and 12% benign prostatic hyperplasia. Only
one malignancy was found. The total cost of additional
referrals was $31,815, or 42% of the cost of screening plus
referrals. As the cost per screening encounter was low,
prostate cancer screening in the workplace is an efficient alternative.

<2>
AN 99308726
AU Elwyn GJ. Rix A. Matthews P. Stott NC.
IN School of Postgraduate Education for General Practice, University of Wales,
Cardiff, UK.
TI Referral for 'prostatism': developing a 'performance
indicator' for the threshold between primary and secondary
care?.
SO Family Practice. 16(2):140-2, 1999 Apr.
LM Dana. Incomplete holdings, check catalog.
AB OBJECTIVE: We aimed to define a performance indicator at the gateway between
primary and secondary care. METHOD: We carried out an
analysis of referral letters sent to an urological
department within the catchment area of a teaching hospital in Cardiff,
Wales. The subjects were 221 sequential referral letters
from 221 GPs. The main outcome measures were the information content of
referral letters analysed. Letters were stratified into
referral threshold groups by the presence of history,
examination, routine investigations and specialized
investigations. RESULTS: Three distinct categories of
referral practice were identified:
referrals which contained history alone; those providing
history examination and a selection of routine
investigations; and those providing history, examination
data and the results of routine and
specialized investigations. The study demonstrated that more than a third of
GPs do not report the results of digital rectal examination in their
referrals and only 4% record urinary flow
rates and post-micturition residual urine volume.
CONCLUSIONS: The majority (60%) of generalist referrals to
an urology department for prostatism provide enough information for
specialists to be able to prioritize appointments, but more than a third
(36%) of the referrals contain inadequate information. The
method has the potential of being developed into a gateway performance
indicator in clinical practice.

<3>
AN 99263713
AU Moyad MA.
IN Section of Urology, University of Michigan, Ann Arbor 48109-0330, USA.
TI Nontraditional treatments for localized prostate cancer: ten rules to know
before talking to my patients. [Review] [52 refs]
SO Seminars in Urologic Oncology. 17(2):64-9, 1999 May.
LM Not at Dartmouth/DHMClibraries;request on interlibrary loan.
AB There is accumulating evidence that nontraditional treatments used by the
general population are experiencing a dramatic increase. The use of these
treatments by prostate cancer patients seems to at least parallel or exceed
that of recent surveys for other groups. Unfortunately, much of the attention
of nontraditional treatments has focused on "what to take
and not to take," rather then "how to approach" the use of
these therapies. One of the most widely used nontraditional treatments is the
use of supplements. Outlined here are 10 general rules that the clinician
should know before consulting on these treatments. Recording supplement use
as a part of the general medical history, knowing the general behavior of
supplement users, instructing individuals on the proper time to use
supplements, and focusing on more than prostate cancer for
our example patient are just some of the rules that will enable the health
professional to be better equipped for handling this unique
area of medicine. [References: 52]

<4>
AN 99293308
AU Lodge RN.
IN Department of Urology, Bristol Royal Infirmary.
TI An audit of the investigation and treatment of localised
prostatic cancer in the south west region.
SO Annals of the Royal College of Surgeons of England.
81(2):133-8, 1999 Mar.
LM Pre-1993 Dana; 1993-date MFHSL (Incomplete, check catalog)
AB Prostate cancer constitutes a major health care dilemma in terms of
treatment options available and increasing patient load on
both a regional and national level. An audit was undertaken
of all patients in the South West Region with localised prostate cancer newly
diagnosed in 1993 to assess regional management of this disease. In 1993,
1407 patients were newly diagnosed as having prostatic
cancer. Patients > 75 years old and those with a
prostate-specific antigen (PSA) > 40 ng/ml were excluded, leaving 262
patients whose case notes were examined. The interval between
referral and clinic (mean 67 days) was
altered by the presence of a GP performed PSA, being shorter if the PSA was >
10 ng/ml (average 54 days) than if the PSA was < 10 ng/ml (average 104 days).
Overall, 34% of patients underwent radical treatment (10% radical
prostatectomy and 24% radiotherapy). In all, 27% received
hormone manipulation or orchidectomy, and the remainder
'watchful waiting'. The majority (78%) of patients < 60 years old received
radical treatment, as did 35% of those 60-70 years and 15%
of 70-75 year olds. Over 90% of tumours were category T1 and
were well or moderately differentiated. All patients had a histological
diagnosis and 84% had their tumour staged before treatment.
This study highlighted the need for improvements in patient assessment,
improved note keeping and a regional cancer register to
allow ongoing assessment of patient management. This audit of management of
localised prostate cancer serves as a baseline from which to initiate
and monitor improvements in the service regionally
and will also allow assessment of the impact of such
changes.

<5>
AN 99252375
AU Elwyn G. Jones S. Edwards P.
IN Department of Postgraduate Education for General Practice
and Department of General Practice, University of Wales
College of Medicine, Heath Park, Cardiff, UK.
TI 'Appropriateness of referral to urologists': can it be
defined for symptoms of benign prostatic obstruction
and used as a quality measure?. [Review] [19 refs]
SO BJU International. 83(3):238-42, 1999 Feb.
LM Dana Biomedical Library (Dana).

<6>
AN 99212350
AU Szabo J. Vegh A. Gasman D. Hoznek A. Chopin DK. Abbou CC.
IN Department of Urology, Central Military Hospital, Budapest, Hungary.
TI Biopsy-based diagnosis of prostate cancer in 1290 patients
referred for prostate examination: results according to the
PSA level, digital rectal examination and ultrasonography.
SO Acta Chirurgica Hungarica. 37(1-2):95-100, 1998.
LM Not at Dartmouth/DHMClibraries;request on interlibrary loan.
AB Authors present their retrospective study of 1290 patients
referred for prostate evaluation. The risk of cancer was
analysed according to PSA, rectal palpation and ultrasound
examination. Among the 1290 patients, 54.8% had cancer. The risk of cancer
was multiplied by 2.8 when the PSA was between the normal limit
and 10 ng/ml, by 7.5 when it exceeded 10 ng/ml, by 4.0 when
rectal palpation was abnormal and by 1.6 when a
hypoechogenic zone was present. Although a hypoechogenic zone does not
improve the detection of cancer compared to PSA and rectal
palpation, an increased PSA level even lower than 10 ng/ml indicates
biopsies.

<7>
AN 98217389
AU Naitoh J. Zeiner RL. Dekernion JB.
IN University of California, Los Angeles 90095-1738, USA.
TI Diagnosis and treatment of prostate cancer [see comments].
[Review] [26 refs]
CM Comment in: Am Fam Physician 1998 Dec;58(9):1972, 1977-8
SO American Family Physician. 57(7):1531-9, 1541-2, 1545-7, 1998 Apr 1.
LM Pre-1993 at Dana,1993-date at MFHSL.
AB In the United States, prostate cancer is the most common solid tumor
malignancy in men and second to lung cancer as the leading
cause of cancer deaths in this group. Even though prostate cancer is
responsible for 40,000 deaths per year, screening programs are a matter of
controversy because scientific evidence is lacking that early detection
decreases morbidity and mortality. Furthermore, treatment
decisions are difficult to make because of the generally indolent nature of
prostate cancer and because it tends to occur in older men
who often have multiple, competing medical illnesses. Depending on the
specific situation, radical prostatectomy, radiotherapy or watchful waiting
(observation) will be the most appropriate management option. In general,
localized cancer is best treated with surgical removal of the prostate
gland or radiotherapy. Hormone deprivation therapy is the
primary method of controlling metastatic prostate cancer. At present,
chemotherapy cannot cure disseminated prostate cancer. Watchful waiting is a
reasonable management alternative for prostate cancer in an older patient or
a patient with other serious illnesses. [References: 26]

<8>
AN 99148858
AU Elwyn GJ. Rix A. Matthews P. Stott NC.
TI Referral for prostatism: a 'performance indicator' for the
gate between primary and secondary care? [letter].
SO British Journal of General Practice. 48(433):1528, 1998 Aug.
LM Dana Biomedical Library (Dana).

<9>
AN 98372672
AU Wurzer JC. Al-Saleem TI. Hanlon AL. Freedman GM. Patchefsky A. Hanks
GE.
IN Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia,
Pennsylvania 19111, USA.
TI Histopathologic review of prostate biopsies from patients
referred to a comprehensive cancer center: correlation of
pathologic findings, analysis of cost, and impact on
treatment.
SO Cancer. 83(4):753-9, 1998 Aug 15.
LM Pre-1993 Dana; 1993-dateMFHSL;for Web access-check catalog
AB BACKGROUND: Clinicians at the Fox Chase Cancer Center (FCCC) base prostate
carcinoma treatment decisions regarding need to treat, field size, total
dose, and adjuvant hormonal therapy on known prognostic
factors including clinical stage, Gleason score (GS), perineural invasion
(PNI), and pretreatment prostate specific antigen levels.
The pathology of every patient is reviewed at FCCC to confirm a diagnosis of
malignancy. The objective of this study was to define differences between
pathologic reviews and their impact on treatment between
outside institutions and FCCC. METHODS: The authors reviewed
538 pathology reports of prostate biopsies performed at both outside
pathology departments and FCCC on patients evaluated between
January 1993 and December 1996. The outside pathology
reviews represented 107 community hospitals, academic institutions,
and private pathology laboratories. Patients who had
received hormonal therapy, cryosurgery, or radical prostatectomy prior to
prostate biopsy were excluded from analysis. Final FCCC pathology
determinations were compared with pathology reports from outside
institutions. Reports then were analyzed to determine whether differences in
interpretation would have resulted in different treatment strategies.
Differences in percentages according to institutional type were evaluated
using the chi-square statistic. The cost was assessed and
cost per change in treatment estimated. RESULTS: The 538 pathology reviews
identified a nearly 40% change in GS and a 13% change in >
or =2 GS between the FCCC pathology review and 107 outside
academic institutions. The results of this study showed that 22% of community
hospitals, 10% of private laboratories, and 8% of academic
institutions demonstrated at least 2 GS changes compared with the FCCC
pathology review (p = 0.001). There was no significant difference observed
between types of institutions in the incidence of PNI. CONCLUSIONS: This
analysis provides evidence of a significant difference in the pathologic
reviews of prostate biopsies conducted at FCCC and outside
pathology departments. There was a nearly 40% change in GS
and a 13% change in > or =2 GS between the FCCC pathology
review and 107 outside institutions. The second pathology
review added approximately $104 per case for a total of $55,952 to review all
538 cases. Overall, the savings in health care dollars resulting from the
second pathologic review totaled $12,997. This second review of outside
pathology in prostate cancer appears to be justified based on the treatment
changes and on cost.

<10>
AN 98337471
AU Fowler FJ Jr. Bin L. Collins MM. Roberts RG. Oesterling JE. Wasson JH.
Barry MJ.
IN Center for Survey Research, University of Massachusetts, Boston, 02125, USA.
TI Prostate cancer screening and beliefs about treatment
efficacy: a national survey of primary care physicians and
urologists [see comments].
CM Comment in: Am J Med 1998 Jun;104(6):602-4
SO American Journal of Medicine. 104(6):526-32, 1998 Jun.
LM Pre-1993 Dana; 1993-dateMFHSL;for Web access-check catalog
AB PURPOSE: To describe practice patterns and beliefs of
primary care physicians and urologists regarding early
detection and treatment of prostate cancer. SUBJECTS
AND METHODS: National probability samples of primary care
physicians (n=444) and urologists (n=394) completed mail
survey instruments in 1995. Physicians were asked about their use of
prostate-specific antigen (PSA) testing for men of different ages
and their beliefs about the value of radical prostatectomy,
external-beam radiation therapy, and watchful waiting for
men with differing life expectancies. RESULTS: Most primary care physicians
report doing PSA tests during routine examination of men older than 50 years
of age. The majority say they continue to do them on patients over 80 years
and to refer men with abnormal values for
biopsy. In contrast, only a minority of urologists would recommend PSA tests
or biopsy for abnormal values for men over 75 years of age. More than 80% of
primary care physicians and urologists doubt the value of
radical prostatectomy for men with < 10 years of life expectancy; more
primary care physicians than urologists see probable survival benefit in
radiation therapy for patients with life expectancy < 10 years (48% versus
36%) or > 10 years (67% versus 53%). Thirteen percent of primary care
physicians and only 3% of urologists consider watchful
waiting to be as appropriate as aggressive therapy for men with > 10 years of
life expectancy. CONCLUSIONS: Primary care physicians are more aggressive
about PSA testing and referral for biopsy
than most urologists recommend. Both groups recommend PSA testing
and believe that aggressive treatment is more beneficial
than existing evidence indicates.

<11>
AN 98222354
AU Bergdahl S. Aus G. Lodding P. Norlen L. Hugosson J.
IN Department of Urology, Goteborg University, Ostra Hospital, Sweden.
TI Lower urinary tract symptoms. A comparison of micturition symptoms in
patients scheduled for transurethral prostatic resection
and outpatients of both sexes referred for
non-urological complaints.
SO Scandinavian Journal of Urology & Nephrology. 32(1):20-5,
1998 Feb.
LM Dana. Incomplete holdings, check catalog.
AB The presence of ten different micturition symptoms was investigated by means
of a patient-administered questionnaire in 355 males and
females over 50 years of age referred for non-urological
complaints, and compared to those of 131 patients selected
for transurethral prostatic resection (TURP) due to
symptomatic benign prostatic hypertrophy. Each symptom was
evaluated further by a subsequent "bother" question and the
questionnaire also contained a global "bother" question. Each of the symptoms
was significantly more frequent and pronounced in the TURP
group than in the control group. Moderate or severe symptoms were found in
25% of males and 18% of females in the control group as
compared to 92% in the TURP group. In the control group most symptoms
increased with age regardless of sex, and this was most
pronounced for weak stream and hesitancy. Males in the
control group had a significantly higher total symptom score than females
(5.3 vs 4.3; p < 0.05). This difference was, however, mainly due to higher
scores in weak stream, hesitancy and post-micturition
dribbling in males. Females tended to have more urgency. The symptom scores
and the associated "bother" scores were highly correlated,
indicating that each symptom carried the same potential to bother the
patient. The single global "bother" question gave an adequate reflection of
the combined "bother" scores, and seems sufficient in the
evaluation of the individual patient's concern.

<12>
AN 98240654
AU Amling CL. Blute ML. Lerner SE. Bergstralh EJ. Bostwick DG. Zincke H.
IN Department of Urology, Mayo Clinic Rochester, Minnesota 55905, USA.
TI Influence of prostate-specific antigen testing on the spectrum of patients
with prostate cancer undergoing radical prostatectomy at a large
referral practice [see comments].
CM Comment in: Mayo Clin Proc 1998 May;73(5):489-90
SO Mayo Clinic Proceedings. 73(5):401-6, 1998 May.
LM Pre-1993 Dana; 1993-dateMFHSL;for Web access-check catalog
AB OBJECTIVE: To analyze trends in the clinical stage and
pathologic outcome of patients with prostate cancer who underwent radical
prostatectomy at a large referral practice during the
prostate-specific antigen (PSA) testing era. MATERIAL AND
METHODS: Between January 1987 and June 1995, 5,568 patients
with prostate cancer (4,774 with clinically localized disease of stage T2c or
less) underwent pelvic lymphadenectomy and radical
retropubic prostatectomy at our institution. Patient age, preoperative serum
PSA level, clinical stage, pathologic stage, Gleason score,
and tumor ploidy were assessed. Outcome was based on
clinical and PSA (increases in PSA level of 0.2 ng/mL or
more) progression-free survival. RESULTS: Patient age (65 to 63 years old;
P<0.001) and serum PSA level (median, 8.4 to 6.8 ng/mL;
P<0.001) decreased during the study period. The percentage of patients with
clinical stage T1c prostate cancer increased from 2.1% in 1987 to 36.4% in
1995 (P<0.001), and clinical stage T3 cancer decreased from
25.3% to 6.5% (P<0.001). Nondiploid tumors decreased from 38.3% to 24.6%
(P<0.001), and the proportion of patients with
pathologically organ-confined disease increased from 54.9% to 74.3%
(P<0.001). More cT1c than cT2 tumors were diploid (80% versus 72%; P<0.001),
had a Gleason score of 7 or less (75% versus 65%; P<0.001),
and were confined to the prostate (75% versus 57%; P<0.001).
Five-year progression-free survival was 85% and 76% for
patients with clinical stage T1c and T2, respectively
(P<0.001). CONCLUSION: Since the advent of PSA testing, patients
referred to our institution for radical prostatectomy have
shown a significant migration to lower-stage, less-nondiploid, more often
organ-confined prostate cancer at the time of initial assessment. Cancer-free
survival associated with PSA-detected cancer (cT1c) is superior to that with
palpable tumors (cT2). Whether these trends translate into improved long-term
cancer-specific survival remains to be confirmed with longer follow-up.

<13>
AN 98161475
AU Hoffman RM. Blume P. Gilliland F.
IN Department of Medicine, Albuquerque Veterans Affairs Medical Center,
University of New Mexico, 87108, USA.
TI Prostate-specific antigen testing practices and outcomes.
SO Journal of General Internal Medicine. 13(2):106-10, 1998 Feb.
LM Pre-1993 at Dana,1993-date at MFHSL.
AB OBJECTIVES: To characterize prostate-specific antigen (PSA) testing
practices in a hospital-based primary care clinic, and to
determine the outcomes of PSA testing, including urology
referrals, biopsies, cancers detected, and
cancer treatments. DESIGN: Retrospective cohort study. Data were obtained
from computerized Department of Veterans Affairs (VA) files
and the statewide New Mexico Surveillance, Epidemiology,
and End Results (SEER) tumor registry. SETTING: Primary care
clinics in a university-affiliated VA Medical Center. PATIENTS: Subjects were
1,448 men without cancer undergoing PSA testing in 1993 with follow-up
through 1994. MAIN RESULTS: Twenty-one percent of clinic enrollees at least
40 years of age were tested with PSA, including 58 who were 75 years of age
or older. By the end of 1994, 40.0% (95% confidence interval [CI] 37.2%,
42.8%) were retested; 25.6% (95% CI 21.7%, 29.5%) of initial retesting
occurred within 6 months. Overall, 20.7% (95% CI 18.9%, 22.5%) of PSA tests
in the cohort were for men aged 75 years or older and were
repeated within 6 months. Among the 193 subjects with PSA values > or = 4.0
ng/mL, 86.0% (95% CI 81.1%, 90.9%) were followed-up in urology clinic,
and 46.1% (95% CI 39.1%, 53.1%) underwent biopsy. Only 11 of
51 men aged 75 years or older who were referred to
urologists for an elevated PSA underwent biopsy. Forty cancers were
diagnosed-a detection rate of 2.8% (95% CI 2.0%, 3.6%). Of these, 28 were
organ-confined, 7 had regional invasion, and 3 had distant
metastases. CONCLUSIONS: Primary care providers frequently ordered PSA tests,
but a substantial proportion of testing occurred outside recommended age
ranges and screening intervals. Older patients with elevated
PSA values often did not complete diagnostic workups. Better adherence to
screening guidelines may limit the number of both PSA tests
and urology referrals.

<14>
AN 98183370
AU Anderson RJ.
TI Primary care management of benign prostatic hyperplasia
[editorial].
SO Hospital Practice (Office Edition). 33(3):11-2, 15-6, 21, 1998 Mar 15.
LM Pre-1993 at Dana,1993-date at MFHSL.

<15>
AN 97272520
AU Collins MM. Barry MJ. Bin L. Roberts RG. Oesterling JE. Fowler FJ.
IN General Medicine Division, Massachusetts General Hospital, Boston 02114,
USA.
TI Diagnosis and treatment of benign
prostatic hyperplasia. Practice patterns of primary care
physicians.
SO Journal of General Internal Medicine. 12(4):224-9, 1997 Apr.
LM Pre-1993 at Dana,1993-date at MFHSL.
AB OBJECTIVE: To define primary care physicians' (PCPs) practices in managing
patients with benign prostatic hyperplasia [BPH],
and to compare these practices to portions of the Agency for
Health Care Policy and Research BPH guideline
and urologists' practices. DESIGN: Mail survey.
PARTICIPANTS: Nationwide random sample of PCPs
and urologists, selected from the American Medical
Association Registry. METHODS: Initial mailing, postcard reminder, second
mailing, telephone reminder, final mailing. MAIN RESULTS: Primary care
physicians (n = 444, response = 51%) reported seeing a median of 35 patients
with BPH over the preceding year, in contrast to 240 for urologists (n = 394,
response = 68%). Regarding tests recommended by the guideline, two thirds of
PCPs reported rarely or never using the American Urological Association (AUA)
symptom index, nearly all reported routinely performing digital rectal
examinations, and many (66%) reported routinely ordering
tests to determine the serum creatinine level. Although considered "optional"
by the guideline, more than 90% of PCPs reported routinely ordering a
prostate-specific antigen test, while infrequently using other optional
tests. Regarding "not recommended" studies, a substantial minority reported
selectively or routinely ordering intravenous pyelography (34%)
and renal ultrasound (33%), while two thirds reported rarely
or never ordering these tests. Eighty-six percent of PCPs reported
prescribing medications for BPH over the preceding year; alpha blockers to a
median of 12 patients, and finasteride to a median of 2.
Variation in urology referral thresholds was suggested in
responses to two patient scenarios. CONCLUSIONS: Primary care physicians are
actively managing patients with BPH. Some of their diagnostic evaluations
vary from the recommendations of a national guideline and
urologists' practices. Referral thresholds appear to vary
considerably.

<16>
AN 97131117
AU Cutinha PE. Potts KL. Rosario DJ. Hastie KJ. Moore KT. Chapple CR.
IN Department of Urology, Royal Hallamshire Hospital, Sheffield, UK.
TI A prospective audit of the use of a prostate clinic.
SO British Journal of Urology. 78(5):733-6, 1996 Nov.
LM Dana Biomedical Library (Dana).
AB OBJECTIVE: To assess the efficiency of a prostate clinic
and to determine the treatment outcomes and
the proportion of patients who could potentially be managed by their General
Practitioners (GPs). PATIENTS AND METHODS:
Referral letters from GPs were screened by the consultant
urologists and appropriate patients seen in the next
available prostate clinic. The initial assessment consisted of an
International Prostate Symptom Score and a medical history,
uroflowmetry, ultrasonographically determined post-void urine volumes, renal
function tests and measurement of prostate specific antigen,
in addition to a physical examination and a digital rectal
examination. Further investigations were requested as required. RESULTS: Over
a period of 18 months, 403 patients were seen, 90% of them within 12 weeks
from the time of referral. Uroflowmetry was performed in 96%
of patients and further urodynamics in 22%. Bladder outlet
obstruction was diagnosed in 246 (61%) patients and primary
detrusor instability was detected in 20 (5%) patients. Fourteen per cent of
patients were returned to the care of the GP following their first visit. The
audit identified a potential group of patients (52%) who could be managed by
their GP. Seven per cent underwent prostate surgery for the relief of bladder
outlet obstruction. CONCLUSION: The prostate clinic significantly reduced the
delay for patients to be seen at the hospital and
facilitated rapid assessment and investigation, much of
which was carried out by a nurse practitioner during the first visit (in most
cases). Several patients were identified who could be managed in the
community.

<17>
AN 97036306
AU Rogers E. Gurpinar T. Dillioglugil O. Kattan MW. Goad JR. Scardino PT.
Griffith DP.
IN Department of Urology, Meath Hospital, Dublin, Ireland.
TI The role of digital rectal examination, biopsy Gleason sum
and prostate-specific antigen in selecting patients who
require pelvic lymph node dissections for prostate cancer.
SO British Journal of Urology. 78(3):419-25, 1996 Sep.
LM Dana Biomedical Library (Dana).
AB OBJECTIVE: To examine the usefulness of clinical stage, tumour
differentiation and prostate-specific antigen (PSA) level,
alone and in combination, to predict regional nodal
metastases in individual patients with localized prostate cancer. PATIENTS
AND METHODS: The usefulness of digital rectal examination
(DRE), biopsy Gleason sum and PSA, alone
and in combination, to predict nodal metastases in an
individual patient was examined. The study included 689 patients who had
laparoscopic or open pelvic lymph node dissection for clinical stage T1-3
prostate cancer. The Kruskal-Wallis test, Mantel-Haenszel test, chi-squared
test and logistic regression were used for continuous,
ordinal, categorical, and multivariate analysis,
respectively. RESULTS: Of the 689 patients who underwent radical
prostatectomy, 52 (8%) had nodal metastases. Although clinical stage, DRE,
pre-operative PSA level and biopsy Gleason sum were
significantly related in the univariate analysis, only pre-operative PSA
level and biopsy Gleason sum were significant predictors of
lymph node status in a multivariate analysis. However, based on a receiver
operating characteristic curve, a model with satisfactory sensitivity
and specificity could not be obtained. CONCLUSION: Current
estimations of primary prostate cancer biology using pre-operative PSA level,
clinical stage and biopsy Gleason sum are not sufficiently
sensitive to predict nodal metastases, and pelvic
lymphadenectomy remains the definitive method of detection.

<18>
AN 96435381
AU Anonymous.
TI Clinical trials referral resource. High priority trials.
SO Oncology. 10(2):226, 229-30, 1996 Feb.
LM Not at Dartmouth/DHMC libraries;request on interlibrary loan

<19>
AN 96265003
AU Epstein JI. Walsh PC. Sanfilippo F.
IN Department of Pathology, Johns Hopkins University School of Medicine,
Baltimore, Maryland 21287, USA.
TI Clinical and cost impact of second-opinion pathology.
Review of prostate biopsies prior to radical prostatectomy.
SO American Journal of Surgical Pathology. 20(7):851-7, 1996 Jul.
LM Pre-1993 Dana; 1993-date MFHSL (Incomplete, check catalog)
AB Despite numerous studies evaluating second-opinion surgical programs, we are
unaware of work evaluating the cost effectiveness of a second opinion for
pathology prior to surgery. One of six pathologists reviewed the pathology of
the outside needle biopsies of 535 consecutive men referred
to Johns Hopkins Hospital for radical prostatectomy over a 12-month period
(from October 1993 until October 1994) before the men underwent surgery. Of
the 535 needle biopsies initially diagnosed on the outside as adenocarcinoma
of the prostate, seven (1.3%) were reclassified as benign upon pathology
review at Johns Hopkins Hospital. The most common lesion misinterpreted as
adenocarcinoma was adenosis or less pronounced examples of adenosis
consisting of foci of crowded glands (five cases). Foci of
atrophy in the remaining two cases were misdiagnosed as adenocarcinoma of the
prostate. Upon subsequent clinical work up, six of seven men were considered
not to have adenocarcinoma, and their surgery was cancelled.
The cost for reviewing all 535 preoperative needle biopsies was $44,883,
which included the cost of immunohistochemical studies for
high-molecular-weight cytokeratin and repeat biopsies
and ultrasounds in men whose diagnoses were reversed. The
total cost of the radical prostatectomies had the six men undergone surgery
was estimated at $85,686, including hospitalization, anesthesia, radical
prostatectomy pathology, and surgery. This cost savings did
not include other costs resulting from lost wages, morbidity, or potential
litigation. Second-opinion pathological evaluation of prostate biopsy before
radical prostatectomy is cost effective and has a major
impact on clinical treatment for a subset of patients.

<20>
AN 95363783
AU Kirby RS. Chisholm G. Chapple C. Hudd C. Swallow M. Shore D.
IN Western General Infirmary, Edinburgh, Scotland.
TI Shared care between general practitioners and urologists in
the management of benign prostatic hyperplasia: a survey of
attitudes among clinicians.
SO Journal of the Royal Society of Medicine. 88(5):284P-288P, 1995 May.
LM Dana. Incomplete holdings, check catalog.
AB Recent community-based population surveys have revealed a much greater
prevalence of benign prostatic hyperplasia than previously
suspected. From these data it has been projected that there may be more than
2 million men in the UK whose quality of life is to some extent impaired by
this disorder. Since there are only 330 fully trained urologists in this
country it will not be feasible for every individual presenting with
prostatism to be assessed by a specialist. In an attempt to provide a more
rational basis from which family practitioners can decide whether or not to
refer a patient for a specialist opinion a 'shared care'
flow diagram was developed and assumptions contained within
field tested by means of a postal questionnaire which was sent to 2020
urologists, family practitioners and other interested
clinicians. There was general agreement with most of the precepts set out in
the flow diagram, the main exception was a rejection of the suggestion that
every patient with prostatism should have a prostate-specific antigen level
determined before referral. We conclude that there seems a
consensus among respondents that a shared care approach to the management of
BPH may both improve the standard of care provided in this
area by family practitioners and allow hard pressed
urologists to focus greater attention on those patients whose conditions
require surgical expertise to resolve.

<21>
AN 95265570
AU Chisholm GD. Carne SJ. Fitzpatrick JM. George NJ. Gingell JC. Keen JW.
Kirby RS. Kirk D. O'Donoghue EP. Peeling WB. et al.
IN University Department of Surgery/Urology, Western General Hospital,
Edinburgh, UK.
TI Prostate disease: management options for the primary healthcare team. Report
of a working party of the British Prostate Group.
SO Postgraduate Medical Journal. 71(833):136-42, 1995 Mar.
LM Pre-1993 at Dana,1993-date at MFHSL.
AB The prostate gland has attracted a remarkable increase in
interest in the past few years. The two most common diseases
of this gland, benign prostatic hyperplasia
and carcinoma of the prostate, have been brought into
greater prominence by new diagnostic methods, public interest,
and a wider choice of surgical and
non-surgical treatments. Uncertainty about the significance of these changes
has occurred because of the rapidity of change, the profusion of statements,
opinions and promotions, and the relatively
little guidance available from the profession. Ten urologists
and two general practitioners have reviewed the relevant
evidence about these two prostate diseases
and the newer diagnostic methods; their conclusions are
summarised here. Management options and guidance on clinical
practice are also discussed. Because of a number of unresolved diagnostic
and management issues, detailed requirements for practice
guidelines have not been specified.

<22>
AN 95234531
AU Cheson BD. Phillips PH. Kaplan RS.
TI Clinical trials referral resource. Prostate cancer II.
SO Oncology. 9(1):50, 55, 1995 Jan.
LM Not at Dartmouth/DHMC libraries;request on interlibrary loan

<23>
AN 95194822
AU Cheson BD. Kaplan RS. Phillips PH.
TI Clinical trials referral resource. Prostate cancer.
SO Oncology. 8(12):35-6, 1994 Dec.
LM Not at Dartmouth/DHMC libraries;request on interlibrary loan

<24>
AN 95116885
AU Andersson L. Hagmar B. Ljung BM. Skoog L.
IN WHO Collaborating Centre for Urological Tumors, Karolinska Hospital,
Stockholm, Sweden.
TI Fine needle aspiration biopsy for diagnosis and follow-up
of prostate cancer. Consensus Conference on Diagnosis and
Prognostic Parameters in Localized Prostate Cancer. Stockholm, Sweden, May
12-13, 1993. [Review] [30 refs]
SO Scandinavian Journal of Urology & Nephrology. Supplementum.
162:43-9; discussion 115-27, 1994.
LM Dana. Incomplete holdings, check catalog.
AB Fine needle aspiration biopsy (FNAB) and ultrasound-guided
core biopsy using biopty gun both have a high, and
approximately equal, accuracy in diagnosing and grading
prostate cancer. The TRUS-guided technique provides a better estimation of
the tumor extent and to some degree even of capsular
involvement. It is therefore a recommendable part of the preoperative
evaluation when radical prostatectomy is contemplated. On the other
hand, the aspiration technique usually provides more
epithelial cells. It entails a significantly lower risk of septic
complications and of seeding tumor cells. It has also a
lower cost than the core biopsies. The aspiration biopsy can easily be
performed repeatedly in the follow-up procedure, which is of particular
importance in cases managed with watchful waiting. We recommend the
aspiration biopsy for routine use in the diagnostic work-up
and follow-up. It is essential that not only the cytologic
evaluation but as well the sampling from the prostate is performed with
adequate expertise. [References: 30]

<25>
AN 94076532
AU Hammerer P. Huland H.
IN Department of Urology, University Hospital Hamburg Eppendorf, University of
Hamburg, Germany.
TI Systematic sextant biopsies in 651 patients referred for
prostate evaluation.
SO Journal of Urology. 151(1):99-102, 1994 Jan.
LM Pre-1993 Dana; 1993-dateMFHSL;for Web access-check catalog
AB In 651 patients mapping of the prostate by 6 systematic sextant
ultrasonography guided biopsies was performed without major side effects
using the automatic biopsy gun. The histological findings provided data on
patients with normal and abnormal prostates as determined by
digital rectal examination. Only 3 of 72 nonurological patients (4%) with
normal prostate specific antigen (PSA) levels of less than 4 ng./ml. had
prostate cancer. Of the 259 patients with a firm prostate on digital rectal
examination 105 (41%) had prostate cancer. For those with a PSA level of less
than 4 and 4 ng./ml. or greater the positive biopsy rates
were 13% and 58%, respectively. Of 56 patients with clinical
stage B or C disease and a PSA level of less than 4 ng./ml.
20 (36%) had prostate cancer, compared to 155 of 187 (83%) with a PSA level
of 4 ng./ml. or greater. Transrectal ultrasound was not helpful in screening
for prostate cancer due to the low positive biopsy rate for hypoechoic
lesions. However, among 175 patients with clinical stage B or C disease
transrectal ultrasound identified 157 (90%) with prostate cancer.

<26>
AN 93075609
AU Cheson BD. Ungerleider RS.
TI Clinical trials referral resource.
SO Oncology. 6(11):30, 32, 34-6, 1992 Nov.
LM Not at Dartmouth/DHMC libraries;request on interlibrary loan

<27>
AN 91157331
AU Babaian RJ. Miyashita H. Evans RB. von Eschenbach AC. Ramirez EI.
IN Department of Urology, University of Texas M.D. Anderson
Cancer Center, Houston.
TI Early detection program for prostate cancer: results and
identification of high-risk patient population.
SO Urology. 37(3):193-7, 1991 Mar.
LM Pre-1993 at Dana,1993-date at MFHSL.
AB Three hundred sixty-two men underwent transrectal ultrasound of the prostate
(TRUS), digital rectal examination (DRE), and serum
prostate-specific antigen (PSA) determination as part of an early detection
program for prostate cancer. Thirty-seven (10%) cancers were detected. DRE
had the highest sensitivity and specificity, 89 percent
and 84 percent, respectively. TRUS and PSA
had comparable sensitivities (84% and 81%)
and specificities (82% and 82%). The
positive predictive values of DRE, TRUS, and PSA
determination were 39 percent, 35 percent, and 33 percent,
respectively. We found a cancer detection rate of 16 percent among patients
with symptoms of bladder outlet obstruction and 5 percent in
patients without these symptoms. The detection rate was 36 percent for
physician-referred patients and 3 percent
for self-referred patients. This suggests to us that at the
present time the best utilization of medical resources to increase prostate
cancer detection is to educate men to have annual medical evaluations by
primary-care physicians who are encouraged to incorporate risk assessment
and screening DRE as part of their routine practice. Any man
with either abnormal findings on examination or increased risk should be
referred to a urologist for further evaluation.