Journals Watch - PSA tests, depression and COPD

Too busy to read all the journals? Let Dr Raj Thakkar bring you up to date on the latest research.

Screening for prostate cancer N Engl J Med March 18, 2009 10.1056/NEJMoa0810696
Men often attend our surgeries concerned about prostate cancer. We have little data on how effective the combination of PSA testing and digital rectal examination (DRE) is on the death rate of prostate cancer.

Prostate cancer patients do not appear to benefit from PSA or DRE screening compared with usual care (SPL)

This US-based study aimed to answer this question.

Nearly 80,000 men were involved in the study from 1993 to 2001. They were randomised to receive screening with PSA and DRE or usual care.

Those who received screening had annual PSA blood tests for six years and annual DREs for four years.

Around 85 per cent of men were compliant with screening in the intervention group. Of those in the usual care group, 40 per cent of men had PSAs in the first year of the trial compared with 52 per cent by the last year. In the control group, 41-46 per cent of men had DREs.

A total of 116 per 10,000 person-years developed prostate cancer in the screening group compared with 95 in the usual care group. Death rates were 2 per 10,000 person-years in the screening group compared with 1.7 in the control cohort.

The authors concluded there were no differences between the screening with PSA and DRE compared with usual care.

This may offer reassurance to continue to do what we are doing and to reassure our patients that what we are doing has the backing of medical evidence.

Management of depression in relation to severity scores BMJ 2009; 338: b750
This year's QOF changes require GPs to score an initial depression questionnaire and to then repeat the exercise some weeks later.

This UK-based notes review determined whether prescribing and referral behaviour correlates to the scores on depression severity questionnaires.

A total of 2,294 patient notes were reviewed. Of these, 1,658 patients were assessed using the patient health questionnaire-9 (PHQ-9), 584 the hospital anxiety and depression scale (HADS), and 52 the Beck depression inventory, second edition.

Of these patients, 79.1 per cent assessed by either the PHQ-9 or HADS were prescribed antidepressants and 22.8 per cent were referred to secondary care.

The researchers found that those with higher scores were more likely to have had intervention by drugs or referral to secondary care.

While 83.5 per cent of PHQ-9 patients and 55.6 per cent of HADS patients were classed with moderate-to-severe depression respectively, treatment or referral rates were similar across both questionnaires.

The authors concluded that GPs do not solely rely on the questionnaires to decide on treatment and do continue to take other factors into account.

Perhaps our clinical judgement is still of use in depression.

Faecal occult blood screening for colorectal cancer Gut 2009; 58: 530-5

Identification of colorectal cancer at an early stage may offer a patient a significant survival benefit. This Scottish study assessed the outcome of the first three rounds of faecal occult blood (FOB) screening.

The uptake rate was 55, 53 and 55.3 per cent for the first three rounds respectively. Positive detection for blood was 2.07, 1.90 and 1.16 per cent for each respective round and cancer detection rates were 2.1/1,000, 1.2/1,000 and 0.7/1,000.

The positive predictive values for cancer for each round were 12, 7 and 7.5 per cent and 36.5, 30.3 and 29.1 per cent for adenoma. In the first round, nearly half the cancers detected were Dukes A.

The authors conclude that screening for colorectal cancer by FOB, based on this population study, is comparable with data from research settings and should lead to a reduction in morbidity and mortality.

Bronchodilator use in GOLD stage I COPD Thorax 2009; 64: 216-23

In 2007, the global initiative for chronic obstructive lung disease (GOLD) defined stage 1 (mild) COPD as those with an FEV1 [s40]80 per cent predicted and FEV1/FVC < 70 per cent.

Despite having mild disease, this group of patients can have significant exertional dyspnoea, which may impact on their daily activities and quality of life. This study aimed to assess the effect of bronchodilators on this group.

Nebulised ipratropium bromide 500 microgram was used in this randomised double-blind study. Outcome measures were pulmonary function tests and exercise tests.

Nebulised ipratropium bromide was found to increase FEV1, decrease specific airway resistance and to also decrease exercise dyspnoea. Not surprisingly, the authors conclude that bronchodilators should be used in GOLD stage 1 COPD.

NICE guidelines were published in 2004. They are in the process of being updated and are expected to be published in 2010.

One hopes there will be uniformity between the new NICE guidance and GOLD.

Long-term amiodarone therapy for persistent AF May Clin Proc 2009; 84: 234-42

Patients with AF are managed by rate or rhythm control.

This US-based meta-analysis looked at 12 randomised controlled trials involving over 5,000 patients. Those with persistent (as opposed to paroxysmal or permanent) AF were included and amiodarone versus placebo or a rate-controlling drug were analysed.

It was found that amiodarone was more effective than placebo or rate-controlling drugs in achieving rhythm control, giving 21.3 versus 9.2 per 100 patient-years in sinus rhythm.

In addition, amiodarone was not associated with increased mortality.

However, 5.6 times more patients had to stop taking amiodarone compared with placebo or rate-controlling drugs due to adverse effects. Amiodarone was not associated with an increase in hospital admissions.

The authors concluded that amiodarone, despite adverse side-effects, was a safe and effective treatment strategy in those faced with persistent AF.

  • Dr Thakkar is a GP in Wooburn Green, Buckinghamshire, and a member of our team who regularly review journals

THE QUICK STUDY

  • Prostate cancer screening using DRE or PSA testing offered no benefits over usual care.
  • High depression severity scores are associated with antidepressant prescribing and referral to secondary care.
  • Colorectal cancer screening using FOB should reduce morbidity and mortality.
  • Bronchodilators should be used in GOLD stage 1 COPD.
  • Amiodarone was more effective than placebo or rate controlling drugs in achieving rhythm control in AF patients.

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