Diagnosis and treatment of prostatitis in Canada

OBJECTIVES: There is a general consensus among physicians that the present management of chronic prostatitis is dismal. We undertook a survey of Canadian primary care physicians (PCPs) and urologists to determine the degree and source of frustration and to analyze present practice patterns in this disease. METHODS: Five thousand PCPs and all 545 Canadian urologists were asked to complete a comprehensive computer-assisted telephone survey that explored practice characteristics, attitudes, and diagnostic and treatment strategies in the management of prostatitis. Randomization of attribute banks, adherence to questionnaire routing, validation by on-site monitoring, and possible bias were addressed. RESULTS: Completed interviews were obtained from 10% of PCPs and 28% of urologists. PCPs see on average 3.5 (median 2) patients with prostatitis per month and urologists see on average 21.8 (median 11) patients with prostatitis per month. All physicians experience significantly more frustration in treating prostatitis than they do in treating patients with benign prostatic hyperplasia (BPH) and prostate cancer, and they perceive that prostatitis affects patients' quality of life significantly more than BPH and almost as much as prostate cancer. The degree of frustration and unhappiness in dealing with prostatitis is driven by a lack of confidence and comfort in their ability to accurately diagnose and subsequently rationalize treatment. Most PCPs and urologists continue to employ steps in addition to history and physical examination to establish a diagnosis but only a few PCPs and a third of urologists use specific lower urinary tract cultures. Physicians tend to use trimethoprim or trimethoprim-sulfamethoxazole (TMP-SMX) or a fluoroquinolone as their usual first line therapy for chronic prostatitis. The most commonly used therapeutic strategy (40%) for chronic prostatitis was TMP-SMX as first line therapy and a fluoroquinolone as second line therapy. CONCLUSIONS: There is widespread frustration, discomfort, and lack of confidence in both PCPs' and urologists' perceived ability to manage prostatitis. Physicians have expressed a desire for a better understanding of this disease, simpler and clearer diagnostic guidelines, and more rational treatment strategies.     

Therapeutic paralysis of critically ill trauma patients: perceptions of patients and their family members

BACKGROUND: Neuromuscular blocking agents are used in critically ill patients to induce therapeutic paralysis. These drugs leave patients fully immobile but conscious. Analgesics and sedatives are concomitantly administered with the paralytic agents. Little is known about what patients remember when they receive these combinations of drugs. Even less is known about the experiences and needs of the patients' family members during the patients' paralysis. OBJECTIVES: To obtain recollections of therapeutic paralysis in critically ill adult trauma patients and to determine the psychological, emotional, and educational needs of the patients' family members during the time the patients were paralyzed. METHODS: A qualitative phenomenological approach was used to investigate the "lived" experience of therapeutic paralysis of 11 pairs of subjects. Each pair consisted of one critically ill adult trauma patient and one member of the patient's family. RESULTS: The patients recalled their experience of therapeutic paralysis with vagueness, as if they had been dreaming. Few recalled pain or painful procedures. Patients remembered having nurses and family members provide emotional support and encouragement. Family members understood the rationale for use of the drugs. They remembered being encouraged to touch and talk with patients. The subjects suggested providing additional education about events that occur when paralysis is being reversed. CONCLUSIONS: Two confounding variables may have affected these findings: a liberalized visiting policy and use of effective pain and sedation protocols. Healthcare professionals and patients' family members should monitor bedside conversations and use touch and words of encouragement to support patients during therapeutic paralysis.     

The agreement among urological experts on the diagnostic management of patients with common urological problems

OBJECTIVE: To assess the level of agreement among randomly selected international urologists on the diagnostic management of patients with prostate cancer, bladder cancer, urinary stones or lower urinary tract symptoms (LUTS) arising from benign prostatic hyperplasia (BPH). METHODS: A computer program was used to provide an unbiased format of 53 simulated patients, comprising 13 with prostate cancer, 10 with bladder cancer, 10 with stones in the upper urinary tract and 20 with LUTS from BPH. For each case, the history was provided to the user while information from 60 diagnostic tests could be chosen interactively. Thirty-three university-based urologists participated in the study. The probability that a certain test was used by them in a certain patient [P(test)] and the related costs (Swedish 1995 prices) were recorded. The probability that two urologists would agree (relative measure of agreement, RMA) on whether or not to use one particular test in a certain case was RMA(test) = P(test)2 + [1-P(test)]2 and the mean of this RMA(test) for a certain patient [RMA(case)] was used as a measure of the inter-individual agreement among the urologists on the diagnostic management. The significance levels of the generalized kappa statistic, KG, were also calculated. The correlation between the RMA(case) and the diagnostic groups was analysed. RESULTS: The KG was statistically significant for all cases; the RMA(case) was significantly correlated with the diagnostic groups (rs = 0.86). The agreement in the diagnostic management was the strongest for stones, then for bladder cancer and prostate cancer, and the weakest for BPH. The mean cost for the diagnostic evaluation for one case varied from $455 to $1771 (mean 898) and varied in the diagnostic groups, i.e. $1718 for prostate cancer, $947 for bladder cancer, $400 for stones and $594 for BPH. CONCLUSION: The diagnostic management of urological patients varies greatly among urological experts from the industrial world. As a consequence, the related diagnostic costs might vary by about 400% if prices were similar everywhere. The agreement on the diagnostic management of cases is strongly correlated to the diagnosis. LUTS from BPH seems to be managed with the poorest agreement.     

Heparin-induced thrombocytopenia

Seen from a societal perspective, the health gains that might result from prostate screening are too uncertain to justify the substantial associated costs and adverse health effects. Clinicians who rely on observational screening studies to justify current screening practices should be aware of the potential biases that render conclusions suspect. Medical history documents numerous cases of medical interventions that appeared reasonable at the time, but ultimately proved worthless and even harmful. Before embarking on an ambitious screening program for prostate cancer, clinicians should demand that five basic criteria are satisfied: (1) that prostate cancer is a significant health burden, (2) that screening can identify localized disease, (3) that tests used in screening programs have acceptable performance among the population being tested, (4) that the potential for cure is greater among patients with screen-detected disease, and (5) that screen-detected patients have improved health outcomes compared with those who are not screened. Randomized trials provide the best methodology for determining the efficacy of screening and treatment. Clinicians are often too quick to credit medical intervention for successful outcomes and blame tumor biology for disease progression. Furthermore, when faced with a decision of administering or withholding therapy, physicians generally wish to err on the side of having done everything possible. Data modeling can provide critical insights concerning these issues using currently available information. Three recently published models suggest that the overall benefit to a population of men screened for prostate cancer can be measured in days of additional time of life gained, not months or years. Furthermore, models suggest that a substantial number of men need to undergo treatment in order to avert a single cancer death. The costs of implementing a screening program are enormous and deflect resources away from alternative uses, such as increased basic science funding to identify a cure for this disease. Therefore, based on the evidence presented, I believe that without more substantial data supporting the efficacy of screening programs, screening for prostate cancer is neither appropriate nor cost-effective.     

1997 American Urological Association Gallup survey: Changes in diagnosis and management of prostate cancer and benign prostatic hyperplasia, and other practice trends from 1994 to 1997

PURPOSE: The American Urological Association first commissioned the Gallup Organization to conduct a study to assess urologist practice patterns in 1992. We present the results of the 1997 survey, the sixth consecutive Gallup survey performed for the Association. MATERIALS AND METHODS: A random sample of 502 American urologists who had completed urological residency and practiced at least 20 hours weekly in 1996 was interviewed by telephone in February and March 1997. RESULTS: Emerging trends showed significant changes since 1994 in how urologists diagnosed and treated prostate cancer. The survey revealed a significant change in the tests routinely ordered to stage newly diagnosed prostate cancer and for diagnostic evaluation of patients with benign prostatic hyperplasia. CONCLUSIONS: Urologists are becoming more cost conscious and effective in ordering pretreatment testing. Urologists are becoming more oriented toward medical treatment for the management of benign prostatic hyperplasia, and less laser surgery is being performed.     

Patient use of treatment-related information received from the Cancer Information Service

This study explored patient information-seeking behavior and how such behavior might affect patient-physician interaction or health-care decisions. Telephone interviews were conducted with 257 patients with cancer and their relatives who called the National Cancer Institute's Cancer Information Service (CIS) and who received treatment-related information. Results indicated that these patients were generally very satisfied with communication from their treating physicians, had strong information needs, and preferred to participate in their treatment plans. They sought information from CIS just after diagnosis (49%) or during treatment (31%). Many of these patients (42%) discussed the CIS information with their physicians and 19% of these physicians sought more information or consulted a CIS referral. CIS referrals were contacted personally by 18% of patients. Stepwise discriminant analyses indicated that, compared with patients who did not, patients with either of these outcomes were more stressed by their disease and had been seen at more hospitals. Additionally, patients who shared CIS information with their physicians were also younger and more trusting that their physicians had current knowledge. Patients who themselves contacted a CIS referral were also more educated, had higher information needs, were less satisfied with the clarity of physicians' answers to their questions, called CIS earlier in their illness, and called specifically for a referral. Overall, these patients' most common information needs were for exploring all treatment options and being knowledgeable when discussing treatment plans with physicians. The information received from CIS satisfied these needs and was often communicated to their physicians.     

Variability of rectal examination of the prostate among various groups of observers

Rectal examination (RE) of the prostate gland is compulsory to rule out the presence of prostate cancer (PC). Empirically, it is defined as an examination burdened with a high degree of subjectivity and difficult to reproduce. The objective of this retrospective study is to evaluate RE concordance between different groups of researchers. In 133 patients referred to our Centre with suspected PC, RE was performed by three groups of experimented urologists (2 in-hospital and 1 out-hospital). Concordance between the different groups was evaluated using Kappa's index (K). Kappa's index between out- and in-hospital urologists was 70%, 71% and 78%. Concordance of RE findings between the different groups of urologists can be considered good, since no significant differences were found relative to ER positive predictive value.     

A nationwide survey of practicing urologists: current management of benign prostatic hyperplasia and clinically localized prostate cancer

PURPOSE: Our aim was to define the spectrum of urological care for benign prostatic hyperplasia (BPH) and clinically localized prostate cancer. MATERIALS AND METHODS: In 1995 a random sample of 394 American urologists was surveyed with a response rate of 67%. RESULTS: Respondents reported seeing a median of 240 BPH patients during the preceding 12 months, and they had prescribed alpha-blockers for 70 and finasteride for 15. They had performed a median of 25 transurethral prostatectomies but few other operations for BPH. Almost all urologists routinely used digital rectal examinations and prostate specific antigen tests for BPH diagnosis. The next most common studies were American Urological Association symptom scores and uroflowmetry. Pressure-flow studies were rarely done. Respondents reported seeing a median of 35 new patients with prostate cancer during the last year, and performing a median of 90 prostate biopsies and 13 radical prostatectomies. Respondents had referred a median of 10 patients for external beam radiotherapy but few patients received brachytherapy or cryotherapy. Urologist staging practices varied considerably. CONCLUSIONS: These data provide a picture of current practice regarding the management of BPH and prostate cancer.     

Reocclusion following successful thrombolysis. Emerging concepts

The behaviour of physicians is increasingly coming under scrutiny and attack, both from patients and from institutions that represent the public interest. This social process is partly a necessary and healthy quest for healing and partly a retaliatory response to inevitable failures on the part of physicians to live up to the standards expected of them. The process can assume such ruthless and pervasive forms that physicians are becoming exposed to impossible demands and even abuse at the hands of those they are trying to help. As a result, many physicians become defensive, withdrawing from patient care or reasserting their own needs in regressive ways that further offend or injure their patients. This increases public anxiety and outrage resulting in regressive and even violent "solutions", creating a vicious cycle in which mutual trust and respect is eroded and true health eludes our grasp. Physicians who practise psychotherapy are particularly aware of such regressive emotional pressures and therefore their experience can be taken as a bellwether of social change. Stirred by recent encounters with colleagues who have undergone public inquisition, humiliation and punishment, and drawing on personal clinical experience with patients whose regressive self-expression could at times be considered "borderline", the author attempts to understand the nature of the emotional forces being experienced by members of the profession at large. As in therapy, so in social change; the outcome depends on how well we understand, contain and channel the powerful feelings that underlie whatever actions are taken.(ABSTRACT TRUNCATED AT 250 WORDS)     

Antiandrogen withdrawal syndrome

The antiandrogen withdrawal syndrome was first reported in patients with prostate cancer who manifested disease progression after total androgen blockage therapy with medical or surgical castration and pure antiandrogen, flutamide; discontinuation of flutamide resulted in a decline in prostate specific antigen and, in some cases, with clinical response. Same phenomena have been reported after the withdrawal of casodex, chlormadinone acetate, megestrol acetate, diethylstilbestrol, and estramustine phosphate. Mutations in the androgen receptor(AR) gene were discovered in clinical specimens of human prostate cancer patients who showed this syndrome and some of these being identical to the mutation found in LNCaP prostate cancer cell line. Another mechanism otherwise the point mutation of AR would be also speculated.     

Behavioral therapy: its application to reduce disruptive behaviors of the elderly in nursing homes

Nurses who care for the elderly in nursing homes and auxiliary hospitals have many goals. They provide for the health, recreational, social and emotional needs of their patients. They also strive to increase their patients' levels of self-care and self-respect. Unfortunately, because many patients exhibit disruptive behaviors--striking staff or other patients, throwing temper tantrums, lying on the floor in corridors, refusing to take medication and so on, these desirable goals cannot always be met. What nurses need, in addition to their specialized, medically oriented training, is training in a consistent strategy for handling these problems. Behavioral therapy provides this strategy.     

Brain metastasis model in athymic nude mice using a novel MUC1-secreting human breast-cancer cell line, MA11

OBJECTIVES: This study explored parental attitudes about their interactions with their children's providers when decision making involved critical life situations. We evaluated parents' attitudes regarding the following questions: What was the parents' understanding of their children's health care issues, and what was the parental perception of the professionals' understanding of their children and of themselves? Who should be the principal decision makers for the children? What was the parents' knowledge about advance directives? Did parents want to participate in a process of advance planning to assist with critical life decision making for their children? METHODS: We surveyed all parents attending a conference sponsored by the Massachusetts Department of Public Health for parents of children with special needs. The questionnaire was provided to all parents attending the conference. An announcement was made at the conference requesting parental participation. The 76 respondents constitute a convenience sample of parents of children with special needs sufficient for this preliminary stage of investigation. RESULTS: Of 177 parents attending the conference, 76 (43%) completed the questionnaire. Eighty-eight percent of the participants strongly agreed that they understood their children's conditions. Twenty-one percent stated that they had sufficient understanding of their children's future medical needs, and 21% thought that they had a sufficient understanding of their children's developmental potential. Ninety-nine percent of parents strongly agreed that physicians should share information with parents no matter how serious or potentially upsetting. Ninety-four percent of those parents who thought that their children's physicians understood their own needs also thought that the physicians understood their children's needs. In contrast, only half (55%) of those parents who thought the physicians did not understand their needs thought the physicians understood their children's needs. Ninety-two percent of parents who thought that the physicians understood their needs agreed that the physicians would make the best decisions in crises versus 60% of those who did not think the physicians understood their needs. Seventy-four percent stated that they would consider written guidelines for their children that dealt with critical life situations. All parents who thought their children's conditions were not understood wanted written guidelines. Of those parents who had thought their children would not survive (15 parents), 94% wanted written guidelines. All seven parents who had been told their children would not survive wanted written guidelines. CONCLUSIONS: Parents in this study were generally satisfied with care being provided to their children. Nevertheless, the results clearly suggest goals that could lead to improved capacity for parents and providers to make critical life decisions for and with children. First, physicians must understand the needs of parents to be able to make decisions that would be in the children's best interests. Second, parents should participate fully in critical life decisions for their children and should use written guidelines to assist with the process of these critical life decisions. Our findings strongly support the development of a longitudinal process, initiated early after the onset or discovery of illness and maintained longitudinally throughout the course of a child's illness, to help parents and providers work together in this vital area of health care to children.     

Specificity in social support: Perceptions of helpful and unhelpful provider behaviors among irritable bowel syndrome, headache, and cancer patients.

Perceived social support was assessed among 53 patients suffering from non-life-threatening chronic illnesses (i.e., irritable bowel syndrome or recurrent headache). Ss recalled predominantly helpful support interactions and reported the 3 major types of social support as equally helpful. In addition, irritable bowel syndrome patients, who experience embarrassing physical symptoms, reported fewer instances of tangible assistance than chronic headache patients. Comparisons to cancer patients studied by G. A. Dakof and S. E. Taylor (see record 1990-15055-001) revealed differences in perceived social support as a function of diagnosis. These results offer insight into the needs of patients with noncatastrophic illnesses and suggest that the challenges and tasks confronting these individuals are unique from those encountered by patients with catastrophic diseases. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prostate cancer screening--a physician survey in Missouri

This study investigated prostate cancer screening practices using prostate specific antigen testing (PSA), digital rectal examination (DRE), and transrectal ultrasonography (TRUS) by primary care physicians in Missouri. In 1993, a mail survey was sent to a stratified random sample of 750 physicians whose primary specialty was general practice, family practice, or internal medicine. Three separate mailings resulted in an overall adjusted response rate of 60 percent. Ninety-five percent of physicians were more inclined to use PSA compared with three years previously, with only 45 percent of physicians more inclined to use DRE. An increase in the use of PSA following a negative DRE was reported by 85 percent and a greater inclination to use TRUS following a positive PSA was reported by 90 percent Eighty-six percent agreed with the American Cancer Society (ACS) guidelines on prostate cancer screening. Using logistic regression adjusted across levels of demographic and practice factors, prevalence odds ratios were derived with results indicating that agreement with ACS guidelines and being in private practice are strong predictors of a physician's inclination to routinely screen asymptomatic patients for prostate cancer. Our findings have provided baseline information on prostate cancer screening in Missouri and suggest that primary care physicians view PSA testing as a useful procedure and appear to be using it in a manner similar to the general pattern seen across the country.     

The supportive care needs of newly diagnosed cancer patients attending a regional cancer center

BACKGROUND: The objective of this study was to examine the physical and emotional health status, self-perceived problems, and needs of newly diagnosed cancer patients to determine and plan supportive care strategies. METHODS: A cross-sectional survey of newly diagnosed cancer patients attending a regional cancer center during a 6-month period was performed. Patients with breast, colorectal, head and neck, lung, and prostate carcinoma as well as nonmelanoma of the skin were selected randomly. Patients were interviewed prior to their first appointment at the clinic. Physical health status was assessed using the Symptom Distress Scale, psychologic health status was assessed with the General Health Questionnaire (GHQ), day-to-day functioning with the Rapid Disability Scale, and social support with the modified Sarason's Social Support Scale. Perceived needs were assessed in a number of ways, including identification of patients' specific social concerns and informational needs, and by asking them to list their current problems or concerns. RESULTS: Of 156 eligible patients, 134 completed the interview. One hundred and twenty-nine patients (96%) reported current symptoms that included fatigue (66%), worried outlook (61%), difficulty sleeping (48%), and pain (42%). Forty-four patients (33%) were identified as psychologically distressed with a GHQ score of > or = 6. One hundred and fourteen patients (85%) had informational needs, 89 (66%) indicated > or = 1 social concerns, and 55 (41%) reported a need for assistance with day-to-day living. CONCLUSIONS: Patients with newly diagnosed cancer commonly report symptoms related to fatigue, pain, and psychologic distress. Other frequently reported issues relate to the need for information and social concerns regarding the patients' ability to take care of their home and maintain family and other relationships. Awareness of these issues is important for planning supportive care interventions for newly diagnosed cancer patients.     

Asthma and airway inflammation: potential anti-inflammatory activities of phosphodiesterase inhibitors

Although mental imagery has historically been ignored by the scientific community, it is one of the six most commonly used alternative therapies chosen by cancer patients. Investigations of immune response to psychosocial interventions have been largely anecdotal or quasi-experimental. Although reports of increased survival predominate among cancer patients, few investigators have measured psychological or immunological outcomes to explain the mechanisms that contribute to improved survival. The efficacy of imagery or support groups in patient adaptation (emotionally and physically) to the stresses of cancer, heightened immune function, and improved morbidity and mortality remain uncertain in the absence of objective evidence from randomized, controlled clinical trials. The imagery and group emotional support study pilot (IMAGES-P) is a 12-month feasibility study designed to examine the effect of group support and imagery/relaxation in a randomized, controlled clinical trial, differentiating the effects of these therapy modalities on immune function, quality of life, and the emotional well-being of women who have completed treatment for breast cancer. Secondary aims are to explore the quantitative relationships among emotional well-being, quality of life, and immune function. For this study established clinical trial methodology was used to examine functional immune responses associated with emotional states induced by the therapy interventions. As a pilot study, IMAGES-P will provide direction for future longitudinal studies evaluating the effectiveness of these interventions on emotional well-being and survival.     

Discrimination against gay, lesbian and bisexual family physicians by patients

BACKGROUND: Discrimination against gay, lesbian and bisexual (GLB) patients by physicians is well known. Discrimination against GLB physicians by their colleagues and superiors is also well known and includes harassment, denial of positions and refusal to refer patients to them. The purpose of this study was to identify and quantify the attitudes of patients toward GLB physicians. METHODS: Telephone interviews were conducted with 500 randomly selected people living in a large urban Canadian city. Subjects were asked if they would refuse to see a GLB family physician and, if so, to describe the reason why. They were then given a choice of 6 reasons obtained from consultation with 10 GLB people and 10 heterosexual people. RESULTS: Of the 500 subjects 346 (69.2%) were reached and agreed to participate. Of the 346 respondents 41 (11.8%) stated that they would refuse to see a GLB family physician. The 2 most common reasons for the discrimination (prevalence rate more than 50%) were that GLB physicians would be incompetent and the respondent would feel "uncomfortable" having a GLB physician. Although more male than female respondents discriminated against GLB physicians, the difference was not statistically significant. The proportion of male and female respondents who discriminated increased with age (p < 0.01). CONCLUSIONS: The observed prevalence of patient discrimination against GLB family physicians is significant. The results suggest that the discrimination is based on emotional reasons and is not related to such factors as misinformation about STDs and fear of being thought of sexually. Therefore, educational efforts should be directed against general perceptions of homosexuality rather than targeting specific medical concerns.     

Novel staging tool for localized prostate cancer: a pilot study using genetic adaptive neural networks

PURPOSE: An estimated $1.5 billion is spent annually for direct medical expenses and an additional $2.5 billion for indirect costs for the management of prostate cancer. Today there are several procedures for staging prostate cancer, including lymph node dissection. Despite these procedures, the accuracy of predicting extracapsular disease remains low (range 37 to 63, mean 45%). Use of multiple staging procedures adds significantly to the costs of managing prostate cancer. Recently artificial intelligence based neural networks have become available for medical applications. Unlike traditional statistical methods, these networks do not assume linearity or homogeneity of variance and, thus, they are more accurate for clinical data. We applied this concept to staging localized prostate cancer and devised an algorithm that can be used for prostate cancer staging. MATERIALS AND METHODS: Our study comprised 1,200 men with clinically organ confined prostate cancer who underwent preoperative staging using serum prostate specific antigen, systematic biopsy and Gleason scoring before radical prostatectomy and lymphadenectomy. The performance of the neural network was validated for a subset of patients and network predictions were compared with actual pathological stage. Mean patient age was 62.9 years, mean serum prostate specific antigen 8.1 ng./ml. and mean biopsy Gleason 6. Of the patients 55% had organ confined disease, 27% positive margins, 8% seminal vesicle involvement and 7% lymph node disease. Of margin positive patients 30% also had seminal vesicle involvement, while of seminal vesicle positive patients 50% also had positive margins. RESULTS: The sensitivity of the network was 81 to 100%, and specificity was 72 to 75% for various predictions of margin, seminal vesicle and lymph node involvement. The negative predictive values tended to be relatively high for all 3 features (range 92 to 100%). The neural network missed only 8% of patients with margin positive disease, and 2% with lymph node and 0% with seminal vesicle involvement. CONCLUSIONS: Our study suggests that neural networks may be useful as an initial staging tool for detection of extracapsular extension in patients with clinically organ confined prostate cancer. These networks preclude unnecessary staging tests for 63% of patients with clinically organ confined prostate cancer.     

Influence of HIV epidemic on the incidence of Kaposi''s sarcoma in Zambian children

BACKGROUND: It has been suggested that suppression of adrenal androgens may provide benefit to patients with metastatic prostate cancer refractory to initial hormonal therapy (e.g., orchiectomy). METHODS: The records of 38 patients with metastatic prostate cancer that had progressed after orchiectomy who were placed subsequently on low dose dexamethasone (DXM) with no other concurrent therapy (36 patients received 0.75 mg twice daily and two received 0.75 mg three times daily) were reviewed. Symptomatic status, prostate specific antigen (PSA) measurements, and available radiographic assessments were recorded. Bone scans were reviewed by an independent, blinded evaluator. RESULTS: Symptomatic improvement was experienced by 24 patients (63%), 20 (83%) of whom also had decreases in PSA. Prostate specific antigen values decreased in 30 patients (79%) with decreases 50% or greater and 80% or greater in 23 (61%) and 13 (34%) patients, respectively. Of the 23 patients with PSA decreases 50% or greater, 8 (35%) had radiographic evidence of disease regression, 5 (22%) were stable, 7 (30%) had disease progression, and 3 (13%) did not have serial radiographic exams. Flutamide was discontinued shortly before DXM treatment for 2 of the 23 patients. CONCLUSIONS: Low dose DXM may produce important symptomatic improvement and decreased PSA levels in the majority of patients with hormone-refractory prostate cancer. In addition, a substantial percentage of those patients with decreases in PSA also will have radiographic evidence of disease regression. These results suggest the need for additional prospective controlled studies of DXM as a therapy for hormone-refractory prostate cancer.     

Prostate-specific antigen in the diagnosis of organ-confined treatable prostate carcinoma

Prostate cancer is now the most common cancer and the second most common cause of death from cancer among men. Several studies have shown a frequency of autopsy-detected cancer of 40% in men over 50 years of age. In contrast, the lifetime probability of prostate cancer being diagnosed clinically is only 8%. Thus histologically documented prostate cancer only becomes clinically relevant if the tumors are > 0.5 cm3 and the life expectancy exceeds 10 years. Therapy with curative intention is only possible for organ confined disease. Because disease specific survival is about 80-90% after 10 years for conservative treatment of organ confined disease, early detection of prostate cancer is useful for patients with a life expectancy > 10 years. Organ confined prostate cancer is usually asymptomatic. The use of prostate specific antigen (PSA) combined with digital rectal examination (DRE) results in a 2-3 fold increase in prostatic carcinoma detection rate, especially of organ confined disease, by PSA. In men with a minimally elevated PSA-value of 4-10 ng/ml (Hybritech Assays), 25% will have a prostatic carcinoma regardless of the finding of the DRE, which would have reached clinical significance in the follow-up. The indication for biopsy should be established at an early date. There is no support for the common opinion that early detection programs detect clinically unimportant cancers. 95% of tumor volumes are > 0.5 cm3. Furthermore only 3-5% of subjects show prostate cancer in detection programs though 8% will develop clinical symptoms of prostate cancer during their lifetime. This difference is a reason for longitudinal programs with PSA and DRE control once a year, as proposed by the American Cancer Society and the American and Canadian Urological Association, in contrast to other health care organizations, which would wait with general screening until data from prospective randomized trials with beneficial effects of screening are available. To introduce prostate cancer therapy with curative intention for symptomatic patients as well, the cancer should be detected below a PSA level of 10 ng/ml. Insufficient specificity of PSA (2-4 patients have to undergo biopsies to detect one cancer patient) is still an unsolved problem.