Journals Watch - Prostate cancer, CVD risks and QOF

Too busy to read all the journals? Let Dr Bryan Palmer keep you up to date with the latest research.

Enlarged prostate gland: prostate cancer outcomes appear to have improved in recent years

Prostate cancer outcomes are improving JAMA 2009; 302: 1,202-9
Although conservative management can be a reasonable choice in localised prostate cancer, there is little contemporary PSA era data on outcomes with this approach.

To evaluate the outcomes of clinically localised prostate cancer in the PSA era, the authors used a population-based cohort study of men aged 65 years or older when they were diagnosed (between 1992 and 2002) with stage T1 or T2 prostate cancer and whose cases were managed without surgery or radiation for six months after diagnosis.

After 8.3 years of follow up the authors found that conservative management of clinically localised prostate cancer diagnosed from 1992 through to 2002 had better outcomes than patients diagnosed in the 1970s and 1980s.

This may be due, in part, to additional lead time, overdiagnosis related to PSA testing, grade migration, or advances in medical care. Is this another reason to doubt the usefulness of PSA testing?

Cardiovascular risk factors and life expectancy BMJ 2009; 339: b3,513
This prospective cohort study followed 19,000 Whitehall civil servants for 38 years. During the study period 13,500 died.

The study focused on middle- aged men; their cardiovascular risk was measured at baseline using smoking status, cholesterol and BP to give a risk score.

Of the men examined at entry, 42 per cent were current smokers, 39 per cent had high BP, and 51 per cent had high cholesterol. Over time, two-thirds of the smokers had quit and the mean scores for cholesterol and BP were also reduced by two thirds.

Despite the substantial changes in these risk factors over time, baseline differences in risk factors were associated with a 10-15 year shorter life expectancy from age 50.

I have always wondered how actuaries knew this before us medics.

How ethnic minorities rate GP services BMJ 2009; 339: b3,450
One of the consequences of data collection is being able to study it and the General Practice Assessment Questionnaire used for patient surveys is no exception. This cross sectional analysis of surveys from 2005/6 looked at why ethnic minorities consistently rate GP services poorer than Caucasian patients.

More than 188,000 patients responded to the survey. All aspects of care were rated substantially lower by respondents from three ethnic minority groups (black, Asian, Chinese) than by white patients.

Poorer evaluations of time spent waiting for consultations to begin (rated lowest by Asian patients) and continuity of care (rated lowest by Chinese patients) appeared to reflect worse reported experiences by ethnic minority groups.

The authors concluded that this might represent communication issues or different expectations of care. Adjusting survey results for ethnicity could be justified but health services have a responsibility to meet legitimate patient expectations.

Reducing the risk of breast cancer Ann Intern Med 2009; 151
Trials have demonstrated the efficacy of medications to reduce the risk of invasive breast cancer but this meta-analysis looked at the benefit and harm caused by tamoxifen citrate, raloxifene, and tibolone when trying to achieve this aim.

Using a MEDLINE and Cochrane database search, eight trials of quality were chosen. The US authors noted that biases, trial heterogeneity, and few head-to-head trials limit their review.

Data was lacking on doses, duration and timing of the medications, as well as the long-term effects. Also, more data from non-white and premenopausal women was needed.

Despite this, the authors concluded that the three medications reduce primary breast cancer risk (by seven to 10 events per 1,000 women a year, assuming five years' use) but increase risk of thromboembolic events (tamoxifen risk ratio (RR) 1.93, raloxifene RR 1.60), endometrial cancer (tamoxifen RR 2.13), or stroke (tibolone).

For those at very high risk we would need to translate this into numbers to see if benefit outweighs harm.

An American view of the quality framework Fam Pract 2009 doi:10.1093/fampra/cmp056
This study was designed to compare US and UK practices on pay for performance (P4P) measures prior to programme implementation.

The authors analysed medical record data collected before QOF implementation from randomly selected patients with diabetes or coronary artery disease in 42 UK and 55 US family medicine practices.

They found that following NHS investment in primary care preparedness, but prior to the QOF, UK practices provided more standardised care but did not achieve better intermediate outcomes than a sample of typical US practices.

The researchers concluded that US policymakers should focus on reducing variation in care documentation to ensure the effectiveness of P4P efforts, while the NHS should focus on moving from process documentation to better patient outcomes.

  • Dr Palmer is a former Hampshire GP currently working in Australia, and a member of our team who regularly reviews the journals.


  • Localised prostate cancer outcomes are improving.
  • Cardiovascular risk factors can be associated with a 10-15 year shorter life expectancy from age 50.
  • Ethnic minorities rate GP services poorly compared with Caucasians.
  • Tamoxifen, raloxifene, and tibolone reduce risk of primary breast cancer but carry other associated risks.
  • QOF should focus more on outcomes, according to a US study.

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