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joi, 15 decembrie 2011

Biopsy Referral After PSA Screening Stays Consistent Over Time

Main Category: Prostate / Prostate Cancer
Article Date: 15 Dec 2011 - 0:00 PST

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After the US Prostate Cancer Prevention Trial found cancer in many men with low levels of prostate specific antigen (PSA), many debated which PSA level should lead to a biopsy recommendation. The US Preventive Screening Task Force (USPSTF) recently concluded, amid considerable controversy, that the evidence does not support recommending PSA screening for men under 75 years old at all, because the risks outweigh the benefits. Now, a study shows that physicians in a large Washington state health plan were being conservative in biopsy referral even before the USPSTF recommendation.

"Despite considerable recent debate about lowering the threshold for referring men to biopsy, we detected no change toward more aggressive biopsy referral practices in data spanning more than a decade for one integrated delivery system," says lead author Steven Zeliadt, PhD, of the Department of Veterans Affairs Medical Center in Seattle, Washington. "In fact, we observed an opposite pattern, with biopsies becoming slightly less common over the study period. This may reflect growing awareness of the problems of overdiagnosis and overtreatment - and the fact that many men die with prostate cancer but not from it."

Controversy is longstanding about what PSA threshold should be used to refer men for biopsy. The generally accepted standard is 4.0 ng/mL. However, some have urged lowering the level to 2.5 ng/mL, abandoning a specific cutoff altogether, or measuring the PSA velocity, or change over time, instead of absolute level. Dr. Zeliadt and his colleagues set out to determine if the actual biopsy referral practices in a community setting had changed in response to new recommendations, and to determine if PSA velocity is associated with follow-up biopsy.

The study examined PSA tests in members of Group Health, a health plan in Washington State and Northern Idaho, between 1997 and 2008. The final sample included 111,369 index tests among 54,831 subjects. For each test, the study evaluated the PSA level and velocity and the specific follow-up: receiving a biopsy within a year after the test date; attending a urology appointment within a year without biopsy; additional PSA testing within a year with no urology visit; and no PSA-related follow-up.

The researchers found that of tests with a PSA value greater than 4.0 ng/mL, 28% led to a biopsy within 12 months, and 38.6% were followed up by a urologist but did not result in a biopsy. Biopsies were slightly more common in the early years of the study, but biopsy rates did not differ over time for men with mild to moderate PSA levels. The threshold used for biopsy referral appeared not to change over time.

PSA velocity was strongly associated with biopsy. Among men whose PSA tests exceeded 4.0 ng/mL, those with a rapidly rising velocity were more likely to undergo biopsy. This rate was also consistent across the years of the study. "PSA velocity has been promoted for many years as having value for predicting death from prostate cancer, although several recent studies and evidence from screening trials have demonstrated that in practice, velocity adds little value. This is not surprising given that PSA is a continuous marker, and a rapid rise may be likely to trigger follow-up, thus reducing rates of death from prostate cancer," notes Dr. Zeliadt.

"Even small changes in the PSA threshold can substantially alter the potential harms and benefits of screening. However, providers have limited evidence to help them discuss this with patients," concludes Dr. Zeliadt, who is also affiliated with Group Health Research Institute and the University of Washington. "This study highlights the importance of acknowledging that how aggressively patients are referred for biopsy is an important component of the PSA screening discussion."

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our prostate / prostate cancer section for the latest news on this subject. The article is "Biopsy Follow-Up of Prostate-Specific Antigen Tests," by S.B. Zeliadt, D.S. Buist, R.J. Reid, D.C. Grossman, J. Ma, and R. Etzioni (doi: 10.1016/j.amepre.2011.08.024). The article appears in the American Journal of Preventive Medicine, Volume 42, Issue 1 (January 2012), published by Elsevier.
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duminică, 11 decembrie 2011

Long-Lasting Depressive Symptoms, Physical Impairment Often Follow ICU Stays

Main Category: Depression
Article Date: 10 Dec 2011 - 1:00 PST

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Critically ill patients who recover from a potentially deadly syndrome known as acute lung injury frequently emerge with new, apparently long-lasting depressive symptoms and new physical impairments that make them unable to perform many daily tasks, Johns Hopkins research suggests.

Results of the new study, published in the American Journal of Respiratory and Critical Care Medicine, also suggest that the depressive symptoms frequently precede the new physical impairments, not the other way around. The research team also said the findings may be applicable to patients with other types of disease or injury who spend time in hospital intensive care units hooked up to ventilators that breathe for them.

"When people are discharged from the ICU, we tend, understandably, to focus on their physical health, but our data tell us we need to focus on their mental health, too," says study leader O. Joseph Bienvenu, M.D., Ph.D., an associate professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine. "Depression can make recovery much more difficult. Identifying depressive symptoms early and treating them could make a real difference in how patients fare physically in the long term."

Bienvenu and his colleagues assessed 186 survivors of acute lung injury from four Baltimore hospitals at three, six, 12 and 24 months after they became ill, and surveyed their levels of depression as well as their ability to independently perform important tasks of daily life, such as using the telephone, shopping and preparing food.

The Hopkins team found that 40 percent of the patients developed depressive symptoms in the first two years after discharge even though they had not previously experienced them, and that 66 percent experienced new physical impairments. The average age of patients in the study was 49 years people who should be in the prime of their lives but became disabled and unable to return to work, the researchers say. The researchers are continuing to follow these patients to see if the problems persist for an even longer period of time.

"Patients are burdened for a very long time after their hospital stays," says principal investigator Dale M. Needham, M.D., Ph.D., an associate professor of pulmonary and critical care medicine and physical medicine and rehabilitation at the Johns Hopkins University School of Medicine. "We need to figure out what we can do to help these previously productive people get back their lives."

Needham says it is unclear whether it is the acute lung injury syndrome itself causing the new problems or whether the cause is to be found in how patients are routinely cared for in ICUs. Standard ICU care for patients with acute lung injury often includes deep sedation and bed rest. Long stretches of inactivity are known to cause physical impairment, and the use of high-dose benzodiazepines to sedate ICU patients has been associated with depressive symptoms. Needham suspects that both critical illnesses themselves and typical ICU practices contribute to negative outcomes.

Patients' lungs typically recover relatively quickly from acute lung injury, a syndrome often caused by pneumonia, but also by other infections or trauma. In acute lung injury, the body's inflammatory response is revved up and gets out of control, causing fluid to flood into the breathing spaces of the lungs and respiratory failure. An estimated 190,000 Americans suffer from acute lung injury each year and more than 74,000, almost 40 percent, will die while in hospital.

Needham says it is important that intensivists like himself, and psychiatrists like Bienvenu work together to ensure the best outcomes for patients, a collaboration that is frequently missing in the care of ICU patients.

Bienvenu says he was surprised by the finding that depressive symptoms frequently precede new physical impairments, since the conventional wisdom is that the inability after an ICU stay to do things like grocery shopping, driving and walking long distances causes patients to feel demoralized about the loss of these functions. But the reverse appears to be true, he says. Depressed patients, he suggests, are harder to motivate to do the physical activities necessary for recovery and maintenance of function.

Bienvenu says acute lung injury is considered an archetypal critical illness and that its consequences may be present to one degree or another in patients who have suffered other critical illnesses. "All doctors should look out for these symptoms in their patients who have been in the ICU," he says.

The research was funded by the National Institutes of Health.

Article adapted by Medical News Today from original press release. Source: Johns Hopkins Medicine
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