Chris Robertson

Prostate cancer mortality after introduction of prostate-specific antigen mass screening in the federal state of tyrol, Austria

Objectives. To monitor the impact of screening in a natural experiment by comparing prostate cancer mortality in Tyrol, where prostate-specific antigen (PSA) testing was introduced at no charge, with the rest of Austria, where it was not introduced. Methods. In 1993, PSA testing was made freely available to men aged 45 to 75 years in the Federal State of Tyrol, Austria. At least two thirds of all men in this age range have been tested at least once during the first 5 years of the study. Initially, only total PSA was measured, but free PSA measurement was added in 1995. The IMX assay was used. Digital rectal examination was not part of the screening examination. Results. Significant migration to lower stages has been observed since the introduction of this screening program. A reduction in mortality rates in the rest of Austria from 1993 onward has occurred, with the reduction in Tyrol much greater; the mortality remained fairly constant between 1993 and 1995 and subsequently fell. The trends in prostate cancer mortality rates since 1993 differ significantly between Tyrol (P = 0.006) and the rest of Austria. On the basis of the age-specific death rates averaged from 1986 to 1990, the difference between the number of expected and observed deaths from prostate cancer in Tyrol was 22 in the group aged 40 to 79 years in 1998 and 18 the following year. Conclusions. These findings are consistent with the hypothesis that the policy of making PSA testing freely available, and the wide acceptance by men in the population, is associated with a reduction in prostate cancer mortality in an area in which urology services and radiotherapy are available freely to all patients. It is our opinion that most of this decline is likely to be due to aggressive downstaging and successful treatment and that any contribution from detecting and treating early cancers will only become apparent in the years to come.

Depression and degree of acceptance of adjuvant cytotoxic drugs

An interaction between psychological attitude and outcome in early-stage breast cancer has been postulated, with a possible explanation related to the presumed tendency of depressed patients to be less proactive in obtaining health care. We report on the degree of acceptance of adjuvant chemotherapy in patients with breast cancer who have concomitant depression. Only 20 (51.3%) of the study group accepted and received the proposed chemotherapy compared with 75 (92.2%) of the control group (p<0.0001). Treatment of depression might be essential for tailoring adjuvant treatments with chemotherapy.

Intermittent androgen deprivation for locally advanced and metastatic prostate cancer: results from a randomised phase 3 study of the South European Uroncological Group.

BACKGROUND Few randomised studies have compared intermittent hormonal therapy (IHT) with continuous therapy for the treatment of advanced prostate cancer (PCa). OBJECTIVE To determine whether intermittent therapy is associated with a shorter time to progression. DESIGN, SETTING, AND PARTICIPANTS 766 patients with locally advanced or metastatic PCa received a 3-mo induction treatment. The 626 patients whose prostate-specific antigen (PSA) level decreased to <4 ng/ml or to 80% below the initial value were randomised. INTERVENTION Patients received cyproterone acetate (CPA) 200mg for 2 wk and then monthly depot injections of a luteinising hormone-releasing hormone (LHRH) analogue plus 200mg of CPA daily during induction. Patients randomised to the intermittent arm ceased treatment, while those randomised to the continuous arm received 200mg of CPA daily plus an LHRH analogue. MEASUREMENTS Primary outcome measurement was time to subjective or objective progression. Secondary outcomes were survival and quality of life (QoL). Time off therapy in the intermittent arm was also recorded. RESULTS AND LIMITATIONS 127 patients from the intermittent arm and 107 patients from the continuous arm progressed, with a hazard ratio (HR) of 0.81 (95% confidence interval [CI]: 0.63-1.05, p=0.11). There was no difference in survival, with an HR of 0.99 (95% CI: 0.80-1.23) and 170 deaths in the intermittent arm and 169 deaths in the continuous arm. The greater number of cancer deaths in the intermittent treatment arm (106 vs 84) was balanced by a greater number of cardiovascular deaths in the continuous arm (52 vs 41). Side-effects were more pronounced in the continuous arm. Men treated with intermittent therapy reported better sexual function. Median time off therapy for the intermittent patients was 52 wk (95% CI: 39.4-65.7). CONCLUSIONS IHT should be considered for use in routine practice because it is associated with no reduction in survival, no clinically meaningful impairment in QoL, better sexual activity, and considerable economic benefit to the individual and the community.

The prevalence of lower urinary tract symptoms in men and women in four centres. The UrEpik study.

The topics covered in this section relate to areas of considerable interest for urologists everywhere. The UrEpik study is introduced in the ‘Comments’ section and the results of the study will appear in a series of papers published over the next few months. They will give a new insight into many aspects of LUTS.

Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study

BackgroundIncreasing hospital-acquired infections have generated much attention over the last decade. There is evidence that hygienic cleaning has a role in the control of hospital-acquired infections. This study aimed to evaluate the potential impact of one additional cleaner by using microbiological standards based on aerobic colony counts and the presence of Staphylococcus aureus including meticillin-resistant S. aureus.MethodsWe introduced an additional cleaner into two matched wards from Monday to Friday, with each ward receiving enhanced cleaning for six months in a cross-over design. Ten hand-touch sites on both wards were screened weekly using standardised methods and patients were monitored for meticillin-resistant S. aureus infection throughout the year-long study. Patient and environmental meticillin-resistant S. aureus isolates were characterised using molecular methods in order to investigate temporal and clonal relationships.ResultsEnhanced cleaning was associated with a 32.5% reduction in levels of microbial contamination at hand-touch sites when wards received enhanced cleaning (P < 0.0001: 95% CI 20.2%, 42.9%). Near-patient sites (lockers, overbed tables and beds) were more frequently contaminated with meticillin-resistant S. aureus/S. aureus than sites further from the patient (P = 0.065). Genotyping identified indistinguishable strains from both hand-touch sites and patients. There was a 26.6% reduction in new meticillin-resistant S. aureus infections on the wards receiving extra cleaning, despite higher meticillin-resistant S. aureus patient-days and bed occupancy rates during enhanced cleaning periods (P = 0.032: 95% CI 7.7%, 92.3%). Adjusting for meticillin-resistant S. aureus patient-days and based upon nine new meticillin-resistant S. aureus infections seen during routine cleaning, we expected 13 new infections during enhanced cleaning periods rather than the four that actually occurred. Clusters of new meticillin-resistant S. aureus infections were identified 2 to 4 weeks after the cleaner left both wards. Enhanced cleaning saved the hospital £30,000 to £70,000.ConclusionIntroducing one extra cleaner produced a measurable effect on the clinical environment, with apparent benefit to patients regarding meticillin-resistant S. aureus infection. Molecular epidemiological methods supported the possibility that patients acquired meticillin-resistant S. aureus from environmental sources. These findings suggest that additional research is warranted to further clarify the environmental, clinical and economic impact of enhanced hygienic cleaning as a component in the control of hospital-acquired infection.

Sentinel lymph node biopsy as an indicator for axillary dissection in early breast cancer

Sentinel node biopsy (SNB) is a new component of the surgical treatment of breast cancer that accurately predicts axillary status. Although the procedure is still mainly investigational, many patients are requesting SNB to avoid axillary dissection if the sentinel node (SN) is negative. From March 1996 to December 1999, 373 patients with breast carcinoma and clinically negative axillary nodes underwent breast surgery, mainly conservative, and SNB. If the SN was histologically uninvolved no further surgical treatment was given. All patients were informed in detail and signed a consent form. SNB involved injection of labelled albumin particles close to the primary tumour, lymphoscintigraphy and location of the sentinel node with a gamma probe during surgery. 379 SNBs were performed on 373 patients (6 were bilateral). In 94, the SN was positive and complete axillary dissection was performed. In 285 cases (280 patients) the SN was negative and no dissection was performed: these were carefully followed with quarterly clinical examination of the axilla. A total of 343 years at risk were available for evaluation from which seven cases of axillary metastases were expected. No cases of clinically evident axillary node metastasis have occurred. These findings provide further confirmation of the validity of SNB and prompt us to suggest that it should become the method of choice for axillary staging in small-sized breast cancer.

Finding a benchmark for monitoring hospital cleanliness

This study evaluated three methods for monitoring hospital cleanliness. The aim was to find a benchmark that could indicate risk to patients from a contaminated environment. We performed visual monitoring, ATP bioluminescence and microbiological screening of five clinical surfaces before and after detergent-based cleaning on two wards over a four-week period. Five additional sites that were not featured in the routine domestic specification were also sampled. Measurements from all three methods were integrated and compared in order to choose appropriate levels for routine monitoring. We found that visual assessment did not reflect ATP values nor environmental contamination with microbial flora including Staphylococcus aureus and meticillin-resistant S. aureus (MRSA). There was a relationship between microbial growth categories and the proportion of ATP values exceeding a chosen benchmark but neither reliably predicted the presence of S. aureus or MRSA. ATP values were occasionally diverse. Detergent-based cleaning reduced levels of organic soil by 32% (95% confidence interval: 16-44%; P<0.001) but did not necessarily eliminate indicator staphylococci, some of which survived the cleaning process. An ATP benchmark value of 100 relative light units offered the closest correlation with microbial growth levels <2.5 cfu/cm(2) (receiver operating characteristic ROC curve sensitivity: 57%; specificity: 57%). In conclusion, microbiological and ATP monitoring confirmed environmental contamination, persistence of hospital pathogens and measured the effect on the environment from current cleaning practices. This study has provided provisional benchmarks to assist with future assessment of hospital cleanliness. Further work is required to refine practical sampling strategy and choice of benchmarks.

A randomized, prospective trial of central venous ports connected to standard open-ended or Groshong catheters in adult oncology patients.

Implanted central venous access is practiced extensively in oncology; however, information on the relevance of using the device with a valved catheter (Groshong), compared with an open‐ended catheter, is scarce. The authors investigated the two types of catheters in a randomized trial using the same type of subcutaneous port and evaluated efficacy as well as early and late complications.

Breast carcinoma in elderly women: Features of disease presentation, choice of local and systemic treatments compared with younger postmenopausal patients

Aging remains one of the single greatest risk factors for the development of new breast carcinoma. The aim of the study was to evaluate the relation between biologic features at first diagnosis of breast carcinoma and treatment choice for postmenopausal women ≥ 50 years to optimize treatment in the elderly.

Age-Period-Cohort Models: A Comparative Study of Available Methodologies

This article compares the estimates produced by a number of solutions to the identifiability problem in age-period-cohort models using a series of disease rates with known structure. The results suggest that only those methods that are based on the estimable functions such as curvatures can be recommended for use in all circumstances. The other common approaches that give parameter estimates that are easier to interpret all have induced bias in the estimates. In particular methods based on the minimization of a penalty function to achieve identifiability are only of use if there is no change in the rates with time. Any drift in the rates tends to be expressed as a cohort-based trend. The methods based on individual records introduce a bias if there is a strong age effect in the direction of a decreasing cohort trend and a compensating increase based on period effects. The nonparametric testing method has little power to detect trends in the rates in small tables but ascribes a strong drift in the rates to both period and cohort trends. With careful interpretation, all methods estimate nonlinear components correctly.