Johns Hopkins Gazette: May 19, 1997

In Brief

New prostate cancer test guidelines recommended

Most men between the ages of 50 and 70 don't need an annual prostate specific antigen test because their risk of having a noncurable cancer that can be detected is so small. This was the conclusion reached by a team of Hopkins researchers who published their study results in the May 14 issue of the Journal of the American Medical Association.

"Many men need to be tested only once every two years, a change that could dramatically reduce the costs of prostate cancer screening in the United States," said H. Ballentine Carter, associate professor of urology at the Hopkins Brady Urological Institute.

The study showed that PSA testing every two years is sufficient to identify curable prostate cancer, even when a digital rectal exam does not. The PSA measures a protein made in the prostate gland, and elevated PSA levels can indicate disease. The digital exam can detect an enlarged prostate, which can also indicate disease.

Researchers reasoned that if a man's PSA level is less than 2 nanograms per milliliter at the first test, he isn't likely to develop incurable cancer before being tested again in two years. The researchers found that 89 percent of men with PSA levels between 4 and 5 micrograms per milliliter had curable cancers that required treatment, even though digital exams did not find the cancer. In addition, small, unimportant cancers not needing treatment were detected only 33 percent of the time.

"This means that a physician can feel confident that a man with a PSA between 4 and 5 who has prostate cancer has curable disease," added Carter.

Carter also noted the increased testing costs when PSAs returned false positives. However, he added that reduced frequency of PSA testing would leave some men with unidentified prostate cancer.

"Our results suggest that annual testing for PSA in all men is not a cost-effective way to catch prostate cancer at an early, treatable stage," said Carter. "Annual retesting in these men is not likely to save lives. So, for these men, it's safe to wait an extra year. And, because 70 percent of men age 50 to 70 have PSA levels of less than 2, we can eliminate a lot of unnecessary testing."

New chart helps prostate cancer treatment decisions

Hopkins researchers have developed a new, more accurate chart, called a "nomogram," that will help physicians determine prostate cancer stage and also guide treatment decisions. The chart was published in the May 14 issue of the Journal of the American Medical Association.

The chart combines information from the rectal exam; Gleason score, which examines samples of the prostate and its cells; and prostate specific antigen level, which measures a protein released by the prostate.

"Counseling patients and helping them to choose which treatment they prefer is difficult because the decision depends in part on what level of risk the patient is comfortable with," said Alan Partin, assistant professor of urology at the Johns Hopkins Brady Urological Institute. "A man may want surgery to remove a prostate with early cancer and risk impotence or lack of urinary control. Or, he may want to avoid surgery and be treated with radiation or chemotherapy at an early stage of cancer. These nomograms are an important addition to that decision-making process."

Partin noted that current testing suggests that about 60 percent of men with newly diagnosed prostate cancer have disease that is confined to the prostate.

"Unfortunately, after these men undergo surgery and their prostate is studied, more than half have cancer that has spread from the prostate and may not be curable from surgery alone. The use of nomograms should improve our ability to identify those men who can be best cured by surgery alone."

In 1996 there were more than 317,000 newly diagnosed cases of prostate cancer and more than 41,000 prostate cancer deaths.

Practice makes liver surgery more perfect

Some complicated, high-risk liver operations are safer, easier on patients and less costly when they are performed at medical centers that do a lot of them. This conclusion, presented May 13 at the annual meeting of The Society for Surgery of the Alimentary Tract, came from a Hopkins study of 606 liver resections performed at 36 acute care hospitals in Maryland from January 1990 to June 1996.

When researchers analyzed average length of hospital stay, cost, death rates and relative risk, they found that Hopkins surgeons, who performed 43.6 percent of the surgeries (41 per year), were more successful than surgeons at 35 other hospitals where an average of 1.5 similar procedures were carried out yearly.

The study revealed that patients were five times more likely to die from liver resection surgeries performed at institutions other than Hopkins. While the adjusted average length of stay was slightly higher for patients who had their surgery at Hopkins (11.1 days versus 9.8 days), the adjusted average cost was comparable ($15,435 at Hopkins versus $15,326 at other institutions).

"These findings challenge the current trend in the delivery of health care services that sees many patients being directed away from medical centers that do a high number of complex surgeries toward lower-volume hospitals under the mistaken notion that money will be saved and outcomes won't be compromised," said Toby Gordon, one of the study's authors and Hopkins Hospital vice president. "The study underscores the importance of the role of experience in patient outcomes. There is no substitute for experience."

"Gazette" Getting Ready For Summer Schedule

The next issue of The Gazette will be Tuesday, May 27. Following that edition, the paper will publish every other week, beginning June 9. Subsequent issues will appear on June 23, July 7, July 21, August 4 and August 18.

Weekly issues return on Tuesday, Sept. 2, and then each Monday through the end of the fall semester.

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