Health technology assessment and implications for clinical practice: the case of prostate cancer screening

We describe an initiative to disseminate evidence from systematic reviews about the clinical effectiveness of prostate cancer screening to general practitioners and urologists in Norway. The Norwegian Centre for Health Technology Assessment invited The Norwegian Medical Association, The Norwegian Cancer Society, The Norwegian Board of Health, The Norwegian Urological Cancer Group and The Norwegian Patient Association to develop and disseminate clinical practice recommendations. The clinical effectiveness of prostate cancer screening has been assessed in nine independent systematic reviews, which are summarized in a joint INAHTA report. The conclusion was that there is no evidence from appropriately designed trials that early detection and treatment of prostate cancer can reduce mortality, morbidity or improve quality of life. The number of prostate-specific antigen (PSA) tests analysed in Norway increased by 47% [corrected] from 1996 to 1999; at the county level the increase ranged from 12 to 48%. On this background we disseminated leaflets with information about PSA and prostate cancer to 4100 general practitioners and specialists in urology. The main message was, i) PSA should not be taken in healthy men, ii) if the test is wanted, the physician is obliged to give information about the possible consequences. Despite efforts to anchor the information campaign within the mentioned organizations, this met with notable opposition from The Norwegian Urological Society. A survey among agencies within the INAHTA network showed that more than half of the countries within this collaboration have implemented guidelines or recommendations on prostate cancer screening. In conclusion, evidence obtained through an international collaboration such as the INAHTA collaboration may be used to develop and implement national guidelines or recommendations.     

Evidence-based practice in Hong Kong: issues and implications in its establishment

Evidence-based practice has been widely discussed in the literature, but it is not common or well adopted in nursing practice, both in Hong Kong and other countries. This article aims to examine the relationships between three important elements of evidence-based practice: systematic reviews, clinical guidelines and protocols. Current issues associated with evidence-based practice in Hong Kong are explored. Specific suggestions are given to researchers, practitioners, managers and academics so that the current situation can be advanced.     

Management and treatment of men affected by metastatic prostate cancer: evidence‐based recommendations for practice

Currently, 250 000 men are affected by prostate cancer in the UK. Clinical guidance is crucial for nurses involved in the care delivery for men with advanced prostate cancer and for their families to maximize their quality and quantity of life. It is essential that nurses understand how prostate cancer is diagnosed, can recognize signs of disease progression, are familiar with disease management, and can educate patients and manage any symptoms appropriately and effectively. Therefore, the aim of this paper is to review current evidence‐based guidelines in relation to care delivery for men with metastatic prostate cancer in order to optimize best supportive care. A literature review was conducted in a range of electronic databases (DARE, Cochrane, MEDLINE, BNI, PsychINFO, EMBASE and CIHAHL) to identify studies employing qualitative and/or quantitative methods. National (UK) and European clinical guidelines were also reviewed. Methodological evaluation was conducted and the evidence‐based recommendations were integrated in a narrative synthesis. Supportive care is a person‐centred approach to the provision of the necessary services for those living with or affected by cancer to meet their informational, spiritual, emotional, social or physical needs during diagnosis, treatment or follow‐up phases including issues of health promotion, survivorship, palliation and bereavement. A multidisciplinary and proactive approach to the management of men with metastatic prostate cancer ensures safe and effective supportive care delivery. Nurses involved in the care delivery for this patient group need to be aware of the complex physical and psychological supportive care needs, and evidence‐based management care plans to ensure a personalized and tailored support to optimize quality of life.     

Managing cancer‐related fatigue in men with prostate cancer: A systematic review of non‐pharmacological interventions

The aim of this systematic review was to synthesize the best available evidence informing the effectiveness of non‐pharmacological interventions for managing cancer‐related fatigue in men treated for prostate cancer. This review considered experimental studies that included men with prostate cancer (regardless of staging, previous treatment or comorbidities), aged 18 years and over who were undergoing any treatment, or had completed any treatment for prostate cancer within the previous 12 months. Three interventions were identified for the management of cancer‐related fatigue in men with prostate cancer. Evidence from five studies including 447 participants demonstrates the effectiveness of physical activity, both aerobic and resistance exercise, and from three studies including 153 participants suggesting the benefits of psychosocial interventions including education and cognitive behavioural therapy. Health professionals require knowledge of a range of effective interventions aimed at reducing cancer‐related fatigue in men with prostate cancer and should incorporate those interventions into their patient management. Although physical activity appears to show the greatest benefit, other non‐pharmacological interventions such as education and cognitive behavioural therapy have demonstrated benefit and should also be considered as a strategy in treating this debilitating side effect of cancer and its treatment.     

Benefits of pre‐biopsy multi‐parametric magnetic resonance imaging scanning in the initial assessment of prostate cancer

Traditionally, men referred for investigation of raised prostate specific antigen (PSA) could expect to be investigated via blind TRUS biopsy. In recent years, the availability of pre‐biopsy imaging with multi‐parametric magnetic resonance imaging (mp‐MRI) has allowed urology centres to improve their triage and care of this patient cohort. The ability to identify discrete lesions for more accurately targeted TRUS, stream patients with anterior lesions for trans‐perineal biopsy, and of course to prevent those with no evidence of clinically significant prostate cancer from being subjected to unnecessary procedures has proved pre‐biopsy mp‐MRI a valuable tool in the assessment and diagnosis of prostate cancer. Our service recently audited the impact of the introduction of mp‐MRI on our prostate cancer assessment pathway. An analysis of the outcomes of 1558 referrals over a 2‐year period, and found that pre‐biopsy imaging has resulted in a marked reduction in unnecessary procedures and more accurate targeting of lesions, leading to improved outcomes for patients.     

Guidelines on the management of fibromyalgia syndrome – A systematic review

We compared the methodology and the recommendations of evidence‐based guidelines for the management of fibromyalgia syndrome (FMS) to give an orientation within the continuously growing number of reviews on the therapy of FMS. Systematic searches up to April 2008 of the US‐American National Guideline Clearing House, the Scottish Intercollegiate Guidelines Network, the Association of the Scientific Medical Societies in Germany (AWMF) and Medline were conducted. Three evidence‐based guidelines for the management of FMS published by professional organizations were identified: The American Pain Society (APS) (2005), the European League Against Rheumatism (EULAR) (2007), and the AWMF (2008). The steering committees and panels of APS and AWMF were comprised of multiple disciplines engaged in the management of FMS and included patients, whereas the task force of EULAR only consisted of physicians, predominantly rheumatologists. APS and AWMF ascribed the highest level of evidence to systematic reviews and meta‐analyses, whereas EULAR credited the highest level of evidence to randomised controlled studies. Both APS and AWMF assigned the highest level of recommendation to aerobic exercise, cognitive‐behavioral therapy, amitriptyline, and multicomponent treatment. In contrast, EULAR assigned the highest level of recommendation to a set of to pharmacological treatment. Although there was some consistency in the recommendations regarding pharmacological treatments among the three guidelines, the APS and AWMF guidelines assigned higher ratings to CBT and multicomponent treatments. The inconsistencies across guidelines are likely attributable to the criteria used for study inclusion, weighting systems, and composition of the panels.     

Initial experience of a community‐based prostate cancer risk assessment clinic for men of black and minority ethnicity background

We designed and implemented a community‐based prostate cancer risk assessment clinic targeting men from black and minority ethnicity (BME) background. This service had the dual aims of optimizing detection of prostate cancer within a local BME population, with a secondary goal of encouraging longer‐term engagement with primary care for follow‐up prostate‐specific antigen (PSA) testing in order to facilitate early diagnosis of future disease. “Drop‐in” clinics were set up in strategic locations and, staffed by experienced urology nurses. Risk assessment was offered in the form of a PSA test, and digital rectal examination (DRE). We targeted men of BME background aged between 45 and 75 but all attending individuals were given access to counselling and assessment as appropriate. In total, 312 men attended clinics for risk assessment. We diagnosed nine prostate cancers with histological confirmation, with a further two individuals considered to have prostate cancer based on clinical/biochemical parameters. These findings were consistent with similar previously published reports. Nurse‐led, community‐based targeted risk assessment is feasible, leads to the detection of significant numbers of prostate cancers and is well received by patients.     

Advantages of replacing the total PSA assay with the assay for PSA-α1-antichymotrypsin complex for the screening and management of prostate cancer

Several advantages become immediately apparent when the prostate specific antigen (PSA, or tPSA) assay is replaced by the assay specific for the serum PSA-α1-antichymotrypsin (PSA-ACT) complex. For instance, random contributions to the tPSA value by various serum minor PSA isoforms can be avoided, making possible the determination of a more accurate relation of the PSA-ACT concentration to the tumor activity. Discrepancies in percent free PSA (% fPSA) values from the same specimens due to the use of different commercial kits also can be eliminated, mainly because the PSA-ACT assay does not have the problems in antibody selection and calibrator preparation usually associated with the tPSA assay. We found that at the present time different cutoffs of % fPSA for the differentiation of BPH from prostate cancer must be established for each individual tPSA assay. Cutoffs established using values from one tPSA assay should not be used for making clinical decisions when their tPSA values are determined by a different kit. Moreover, when we monitored the patients during treatment with serum tPSA, specific fPSA, and specific PSA-ACT complex assays simultaneously, it was clear that any interpretation of the patient's clinical status based on tPSA values alone could be misleading. Because there is less PSA-ACT complex in BPH specimens relative to that found in cancer serum samples, expressing fPSA as “fPSA/PSA-ACT × 100” and measuring PSA-ACT complex concentrations instead of tPSA during screening improve the measurable contrast between BPH and prostate cancer. Although individually modest, collectively these advantages can add up to considerable improvements. J. Clin. Lab. Anal. 12:32–40, 1998. © 1998 Wiley-Liss, Inc.     

The Total Health Care Audit System: a systematic methodology for clinical practice evaluation and development in NHS provider organizations

Writing in Medical Education in 1982, Fowkes (1982) noted the lack of general agreement within the medical profession on methods of audit, a deficiency previously articulated by Shaw (1980) and later emphasized by McIntyre (1985). More recently, a study by Black & Thompson (1993) of consultant and junior medical staff in four London district general hospitals revealed that 'many doctors did not understand how to undertake audit', and major research by both Hopkins (1993, 1994) and Buttery et al. (1994) described a multiplicity of methodological deficiencies in the general approaches to audit adopted by clinicians since the promulgation of the White Paper definition in 1989. Soundness of methodological approach is fundamental to securing the success of clinical audit within Provider organizations and is thus central to the generation of measurable improvements in the quality of clinical care being delivered to patients. It is therefore disturbing that methodological deficiencies may still be observed in general approaches to audit (Buttery et al. 1994), with no author yet recommending a formal system for critical inquiry into clinical practice. It was the recognition of the unsatisfactory nature of this situation which led us to develop a system aimed at assessing, in a critical fashion, the quality of the totality of care dispensed within NHS provider organizations. The system is presented here for the first time.     

Lectin and serum-PSA interaction as a screening test for prostate cancer

OBJECTIVES: The present investigation was designed to distinguish prostate cancer and benign prostate hyperplasia by lectin-prostate specific antigen (PSA) binding. DESIGN AND METHODS: The quantitative precipitin method of concanavalin A (Con A)-carbohydrate interaction was explored with the serum PSA of patients suffering from prostatic complications. RESULTS: The carbohydrate content in the precipitate after binding of Con A with serum PSA of prostate cancer was significantly lower than that of benign prostate hyperplasia. This may be due to altered sugar chain structure or less glycosylation of PSA in prostate cancer. CONCLUSIONS: We conclude that a serum value <3.0 microg/ml of the carbohydrate content of Con A-PSA precipitate indicates strong suspicion for prostate cancer and this cut off level is effective in reducing the rate of unnecessary biopsies in men with total PSA value between 4.0 to 10.0 ng/ml.     

Organizational assessment in general practice: a systematic review and implications for quality improvement

BACKGROUND: Quality improvement of organizational aspects in general practice is receiving increasing attention. In particular, the impact of effective organization on preventative care has been recognized. Organizational assessments are typically used as part of professionally led accreditation schemes where there is a tension between externally led quality assurance and internally led quality improvement. The aim of this article is to inform the debate by reviewing the international-peer-reviewed literature on organizational assessments used in general practice settings. DESIGN: Systematic literature review. METHODS: The literature was searched for articles relating to organizational assessment. Titles and abstracts were examined by two independent reviewers and relevant articles obtained. Bibliographies were examined for follow-up references. Data were extracted on the development and use of assessment methods. RESULTS: Thirteen papers describing five organizational assessment instruments were included for detailed appraisal. CONCLUSION: This review discovered a developing field containing different approaches to the measurement of organizational aspects of general practice. Whilst professionally led accreditation is well-developed and dependent on externally led quality assurance, approaches to internally led quality improvement are less well-developed. There is a need for organizational assessment tools designed for the purpose of stimulating internal development.     

Effects of replacing PSA with Stockholm3 for diagnosis of clinically significant prostate cancer in a healthcare system – the Stavanger experience

Abstract

Objective

To describe early experience of replacing PSA with Stockholm3 for detection of prostate cancer in primary care.     

Methodology of patient care for elevated PSA after prostate cancer treatment: A primary care perspective

Prostate cancer (PCa) remains one of the most common cancers in men. Each year there are 230,000 new cases and it causes nearly 30,000 deaths. Elevations in prostate-specific antigen (PSA) after treatment with radiation or surgery can indicate the presence of PCa recurrence. About 15–18% of men treated for PCa will have an elevation of their PSA, which is a source of great concern and will lead to a management discussion with the patient. Approximately 25–33% of men with PCa will experience a recurrence of their cancer after surgery or radiation. This article will discuss the different options for men with a rising PSA after definitive therapy or an attempt at curative treatment for PCa. The purpose of this article is to help the primary care doctor, internist and geriatrician to become knowledgeable about the treatment options of recurrent PCa so that they can participate in the discussion with the patient and help the patient reach a decision regarding treatment and management of the elevated PSA levels, which signal recurrent disease.     

Dry needling: a literature review with implications for clinical practice guidelines

Background:

Wet needling uses hollow-bore needles to deliver corticosteroids, anesthetics, sclerosants, botulinum toxins, or other agents. In contrast, dry needling requires the insertion of thin monofilament needles, as used in the practice of acupuncture, without the use of injectate into muscles, ligaments, tendons, subcutaneous fascia, and scar tissue. Dry needles may also be inserted in the vicinity of peripheral nerves and/or neurovascular bundles in order to manage a variety of neuromusculoskeletal pain syndromes. Nevertheless, some position statements by several US State Boards of Physical Therapy have narrowly defined dry needling as an ‘intramuscular’ procedure involving the isolated treatment of ‘myofascial trigger points’ (MTrPs).

Objectives:

To operationalize an appropriate definition for dry needling based on the existing literature and to further investigate the optimal frequency, duration, and intensity of dry needling for both spinal and extremity neuromusculoskeletal conditions.

Major findings:

According to recent findings in the literature, the needle tip touches, taps, or pricks tiny nerve endings or neural tissue (i.e. ‘sensitive loci’ or ‘nociceptors’) when it is inserted into a MTrP. To date, there is a paucity of high-quality evidence to underpin the use of direct dry needling into MTrPs for the purpose of short and long-term pain and disability reduction in patients with musculoskeletal pain syndromes. Furthermore, there is a lack of robust evidence validating the clinical diagnostic criteria for trigger point identification or diagnosis. High-quality studies have also demonstrated that manual examination for the identification and localization of a trigger point is neither valid nor reliable between-examiners.

Conclusions:

Several studies have demonstrated immediate or short-term improvements in pain and/or disability by targeting trigger points (TrPs) using in-and-out techniques such as ‘pistoning’ or ‘sparrow pecking’; however, to date, no high-quality, long-term trials supporting in-and-out needling techniques at exclusively muscular TrPs exist, and the practice should therefore be questioned. The insertion of dry needles into asymptomatic body areas proximal and/or distal to the primary source of pain is supported by the myofascial pain syndrome literature. Physical therapists should not ignore the findings of the Western or biomedical ‘acupuncture’ literature that have used the very same ‘dry needles’ to treat patients with a variety of neuromusculoskeletal conditions in numerous, large scale randomized controlled trials. Although the optimal frequency, duration, and intensity of dry needling has yet to be determined for many neuromusculoskeletal conditions, the vast majority of dry needling randomized controlled trials have manually stimulated the needles and left them in situ for between 10 and 30 minute durations. Position statements and clinical practice guidelines for dry needling should be based on the best available literature, not a single paradigm or school of thought; therefore, physical therapy associations and state boards of physical therapy should consider broadening the definition of dry needling to encompass the stimulation of neural, muscular, and connective tissues, not just ‘TrPs’.