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Urological Fellowships – the unwritten but almost essential step to a future specialist consultant practice?

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Preamble:
Training in urology in the UK, and indeed globally has seen significant changes in the last decade. This has mirrored the changing face of health care provision within and outside the NHS. For award of a Certificate of Completion of Training (CCT), the Joint Committee on Surgical Training (JCST) has recommended specific guideline criteria for different specialties, including urology. The current structure of urological training in the UK has evolved to prepare a trainee by the completion of training at bare minimum for a general urologist. However, depending on the training environment, trainers and trainee enthusiasm with an early focus of interest, many trainees achieve more than just this bare minimum by way of modular training, especially in their final years of training. Some will carry on with acquisition of specialist skills as junior consultants, but increasingly trainees are opting to go for fellowships in their area of specialist interest. This is almost becoming an unwritten essential step for getting a plum specialist post.

When to start?
Those trainees with a special interest in a particular area (and wish to pursue this after CCT) should start the thought process by the end of second year, and their initial groundwork to identify suitable fellowships by third year. Why the rush? Simple reason: the application time to the start of some fellowships typically lags by a year or more. For example, many North American institutional fellowships have application submission deadlines in January, followed by interviews in February-May, for a fellowship that will start in July the following year (18 month lag!). This rush is even more important if the fellowship is intended to be undertaken prior to end of training as an ‘out of programme experience’ or ‘out of programme training’, as the rules have recently changed as of April 2013 where some Local Education and Training Boards (LETBs), previously called ‘Deaneries’, under the Health Education England will not allow OOPE or OOPT in the final year of training. Refer to www.gmc-uk.org and www.hee.nhs.uk for more details on OOPT and OOPE.

When to go on fellowship?
The options are either doing your fellowship before completing training as an OOPE / OOPT or going on a post-CCT fellowship. When to go depends on your individual interest, personal circumstances, fellowship criteria, your choice and importantly the support of your programme director and local surgical training committee. The advantage of an OOPE/OOPT fellowship before CCT is that when you come back, you have your registrar job and salary to come back to. You also don’t lose your grace period at the end of CCT. The disadvantage is that you may come back specialised and ready for a consultant job, but since you haven’t yet completed your full training, you could miss some good job opportunities while you go back to being a registrar for a year. The advantage of a post-CCT fellowship is that you can start looking for jobs during your fellowship and ideally walk into a consultant (or locum consultant) job, but this requires diligently keeping in touch while you are away. The disadvantage is that you may not have anything to come back to, and you lose your grace period. Either way, it’s a gamble.

Where to go?
Traditionally, the two most popular destinations for fellowships are USA and Australia. Emerging spots include Canada, Europe and home-based UK fellowships. Each place has its pros and cons. Australian fellowships, usually for a year, are supposedly good hands-on experience with a fantastic salary package, proportional to frequency of calls. However they grossly lack research and formal learning opportunities. American and Canadian fellowships are usually 2 years with a year of research and a year of clinical/operative work. The research exposure as well as publishing, critical appraisal and exposure to knowledge is fantastic. For US fellowships, trainees have to sit the USMLE and be ECFMG certified. Canadian fellowships are becoming popular with British trainees as holding the FRCS (Urol) suffices, and there is no need to sit any other exams. They also offer a fine mix of research opportunities and hands-on operative experience. For oncology fellowships, visit www.suonet.org. Good financial planning is crucial, especially for North American fellowships.

 

Jaimin Bhatt
University of Toronto Health Network, Princess Margaret Hospital, Toronto, Canada
Post-CCT SUO Fellow in Urologic Oncology. Completed his urological training in the Oxford deanery (now called Health Education Thames Valley)

 

Editorial: Does performing LND at nephrectomy give a survival benefit or not?

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We read with interest the article by Sun et al. [1] in this issue of the BJU International. We were pleased to see another research group interested in this important aspect of the management of patients with lymph-node-positive non-metastatic RCC. The question of the benefits of lymphadenectomy in such patients could not be answered by the European Organization for Research and Treatment of Cancer randomized trial [2], as only 4% of clinically node-negative patients had micrometastatic disease.

Given some of the complexities involved in the analysis of Surveillance, Epidemiology and End Results data and the particular statistical analysis we used in showing a benefit to increasing nodal yield in patients with positive nodes [3], we were reassured that Sun et al. were able to validate our findings when replicating our data extraction and analysis. They performed two additional analyses and the four results are shown in Table 1.

 

While Sun et al. concluded that multiple imputation introduces bias into the findings, inspection of the estimates of the impact of lymph node dissection (the hazard ratio) appear identical. If bias is a deviation of an estimate from the truth [4], we would argue that Sun et al. found no evidence of bias introduced by the multiple imputation method. This is not to say that all four analyses are free from potential bias – the reported hazard ratios may in fact still be biased results – but that there is no more bias in the multiple imputation model than in the others. In addition, we were somewhat surprised to see the use of a missing indicator approach proposed as less likely than multiple imputation to introduce bias as studies have shown the opposite [5].

Furthermore, the CIs show that the benefit to extent of lymphadenectomy may be as great as a 34% reduction in cancer-related death, with exclusion of all but a 5% increase in death associated with the procedure. CIs provide extremely valuable information, particularly in the setting of marginally significant or nonsignificant P values. Sun et al. could have strengthened their paper on statistical considerations by discussing this further. In fact, we would argue that their additional analyses lend further support to the potential benefit of the extent of lymphadenectomy.

The most notable difference across the analyses is a drift in the P value. We would argue that this mirrors the loss in power associated with the censoring of almost 3000 patients (28%) with missing grades. In addition, grade does not appear to be missing at random, as patients with missing tumour grades were associated with larger tumours, higher local stage, increased probability of nodal involvement and increased risk of kidney cancer death. The censoring of such patients may in and of itself introduce bias, although again the hazard ratios do not seem to reflect this. The devaluation of the P value continues to be an active area of biostatistical research, although in general journals have not foregone its inclusion in favour of an entirely Bayesian approach [6]. We believe that, in this case, Sun et al. have taken a far too traditional approach to interpretation of small differences in P values, particularly in the setting of changing sample sizes.

We agree with Sun et al. that consideration of another randomized trial focused on patients at high risk of nodal involvement or with clinically apparent nodes on CT is warranted based upon our combined results.

Jared M. Whitson and Maxwell Meng
Department of Urology, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA, USA

Read the full article

References

  1. Sun M, Trinh Q-D, Bianchi M et al. Extent of lymphadenectomy does not improve survival of patients with renal cell carcinoma and nodal metastases: biases associated with handling of missing data. BJU Int 2014; 113: 36–42
  2. Blom JH, van Poppel H, Marechal JM et al. Radical nephrectomy with and without lymph-node dissection: final results of European Organization for Research and Treatment of Cancer (EORTC) randomized phase 3 trial 30881. Eur Urol 2009; 55: 28–34
  3. Whitson JM, Harris CR, Reese AC, Meng MV. Lymphadenectomy improves survival of patients with renal cell carcinoma and nodal metastases. J Urol 2011; 185: 1615–1620
  4. Grimes DA, Schulz KF. Bias and causal associations in observational research. Lancet 2002; 359: 248–252
  5. Greenland S, Finkle WD. A critical look at methods for handling missing covariates in epidemiologic regression analyses. Am J Epidemiol 1995; 142: 1255–1264
  6. Goodman SN. Toward evidence-based medical statistics. 2: the Bayes factor. Ann Intern Med 1999; 130: 1005–1013
 

Avoiding treatment in prostate cancer: time and money, please?

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It seems impossible to say anything regarding prostate cancer without inciting emotionally charged controversy, even when based on high-level evidence. The updated prostate cancer guidelines from the National Institute of Clinical Health and Excellence (NICE) this week sparked media attention that focused on the role of active surveillance for low and intermediate risk groups.

 

The newspaper headlines state that patients with prostate cancer have been told to avoid immediate treatment. Whether patients are to go against advice given by their doctor or whether this is an attempt by the government to save money is unclear if the online comments are anything to go by. On a local level, patients who are awaiting treatment are questioning their choices.

The sensational implication is that active surveillance is a novel management strategy that was previously not considered. In fact, the equally controversial guidelines from 2008 promoted this alternative: the phrase “suitable for all options including active surveillance” is expressed frequently throughout the country when discussing individual cases at multidisciplinary team meetings.

There is no doubt that a proportion of men who undergo radical treatments may not benefit. The challenges arise in determining who these men are within the constraints of NHS pathways. A standard pathway for a UK man is to request a PSA blood test from his GP, commonly sparked by concerned relatives or friends and endorsed by high-profile survivors and campaigners. A raised result then triggers a “two-week” urgent suspected cancer referral and a clock ticks with diagnosis, staging and treatment to be completed within a 62-day target.

Inevitably, the urgency of referral will influence patient beliefs regarding the seriousness of their condition. A quick online search of comments on recent mainstream articles will throw up anecdotes from men who have sadly failed “wait and see” policies by progressing and finding themselves with incurable disease. A well informed patient will know that a standard transrectal biopsy will have under-estimated his risk in a third of cases. In this emotional state and limited time-frame, our patients are expected to make a rational decision regarding complex management choices – definitive treatment with associated side effects but the knowledge that every effort has been made to “cure” the disease, or what may be a lifetime of repeated, potentially dangerous, biopsies, blood tests and prostate examinations with risk of failure and “living with cancer”. Active surveillance is hardly an attractive option when considered in these terms.

What’s the answer? Detailed evaluation of prostate disease can be achieved with improved imaging with multiparametric MRI in conjunction with a modern transperineal biopsy technique that evaluates the prostate more thoroughly. Suitable patients for active surveillance (and radical treatment) can then be potentially better selected and counseled with higher confidence. Of course, resources are required for this, but shouldn’t this be what we should be campaigning for? And time to deliver this.

Benjamin Disraeli said, “He who gains time gains everything” and perhaps this is the greatest gift we can give to our patients. The lack of time pressure in terms of clinical urgency in low risk prostate cancer gives ample opportunity to get it right in these patients.

I can’t agree that the NICE guidelines are designed to cut NHS costs (active surveillance may cost the same as surgery) but I do fear that without better resources and the reduction in target pressures for low risk prostate cancer, active surveillance will remain an under-utilized management option for many who would benefit from it.

Peter Acher

Should we beware of the patient bearing gifts?

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Whilst I was observing a doctor in an oncology clinic, the doctor mentioned to me a gift she had received the previous week from a patient after giving her the wonderful news that she was cured of her lung cancer. This gift was a pair of concert tickets, which clearly cost a lot of money, and made me think about the ethical issues of, and the regulations behind, receiving a gift from a patient. However, thieves and con-artists don’t give up easy, so here are the tactics you can expect them to use. You can expect them to represent themselves using domain names that sound like government agencies. Names such as Obama Modification, or Obama Housing Plan, and similar names. They will buy.org domains to present themselves as non-profit agencies. For instance, there are bankruptcy Long Island Personal Injury Law Firm, family law and divorce lawyers, tax lawyers, etc. There is no area of practice known as loan modification. Many attorneys can provide help with a loan modification. But, it’s important to understand, that the only party that can modify your mortgage is the lender. Well you can read some tips here for mortgage investment. Check out Mortgage consultants in Queensland for the best service. The attorney can only help facilitate it. It’s fine, even a good idea to retain an experienced attorney to help you when you are faced with a financial hardship and the possibility of losing your home.  A law firm is a law firm and has no need to qualify itself as back, based, or driven. If you are facing these issues, most law firms offer free consultations to discuss your case. Take that opportunity to meet with an attorney and find out how they can help you. It will cost you nothing and may save you not just thousands of dollars, but very likely will save your home as well. David Miller is a freelance writer and marketing consultant. He has written extensively about bankruptcy, debt settlement, debt consolidation, credit and credit cards, collection agency abuse, consumer law, credit card defense, FDCPA guidelines and complaints, loan modification scams, and foreclosure.

Injury cases can be very complex for an average person to deal with, especially if that person is injured and under a lot of stress. If you are injured, then the last thing you should be focusing on is paperwork and legal semantics. This is just one reason why hiring a personal injury attorney may be best for you. These attorneys will automate the entire legal process for you, so you won’t have to worry about filing any paperwork. Another reason why hiring a personal injury attorney would be a good idea is to receive reparations for any property damage that may have occurred during the incident in which you were injured. Often times property damage and injuries go hand and hand. Aside from receiving financial health aid, it would be best to ensure the safety and well being of your property as well, and a personal injury attorney can help you with that. You can read this article for more information about the Chicago Personal Injury Lawyer.

 It is human nature to show gratitude for a deed done. This is why after a doctor has treated a patient they are sometimes presented with a gift from the patient or a relative. This becomes particularly apparent at Christmas time with long-term patients whom doctors see on a regular basis. This gift is usually simply a token of their gratitude towards the doctor and is meant in good will. Of course, the gift may not be given in gratitude, but meant as a bribe or used as a way of manipulating the physician into a particular treatment decision. Thus, receiving and accepting this gift raises a few ethical dilemmas. The acceptance of the gift can be suggestive of bribery and favouritism when it comes to treating the patient on a subsequent occasion or even influencing the doctor’s treatment decision if received part way through treatment. The GMC guidance in ‘Good Medical Practice’ (GMC, 2013) states in their ‘Honesty in Financial Dealings section’:

“You must not ask for or accept – from patients, colleagues or others – any inducement, gift or hospitality that may affect or be seen to affect the way you prescribe for, treat or refer patients or commission services for patients. You must not offer such inducements.”

Under the Bribery Act (2010), bribery is defined as “inducement for an action which is illegal, unethical or a breach of trust” with inducements being in the form of “gifts, loans, fees, rewards or other privileges”. Thus clearly this is a relevant piece of legislation to the ethics of receiving a gift from a patient.

Gifts can often range from tickets to a concert or show, money, high street shop vouchers, wine, or just a box of chocolates. The value of the gift, in terms of monetary value, is more important than what the gift actually is. Where these gifts are easy to share, for example a box of chocolates, then most healthcare professionals would place these in the staffroom or nurses’ office for everybody to share. The current General Medical Services (GMS) contract states that any gift worth over £100 must be declared and the details must be kept in a register at the hospital or surgery (MPS, 2013). Of note, individual hospital trusts will have their own rules, so it is worth finding out what your local policy is. For example, one hospital trust clearly states that while small gifts e.g. chocolates are ok up to a value of £25, larger gifts e.g. wine or food hampers are not and should be refused and entered onto the hospitals gift register.

If local rules are not followed, not only would it constitute a breach of employment with the ultimate sanction being dismissal, the doctor who received the gift may even be accountable on the Bribery Act charge, which has the maximum penalty of 10 years in prison and an unlimited fine. The advice given is that if you do accept a gift, you must declare it, be able to prove that it did not influence your treatment decisions regarding that patient and to make sure that the patient is aware of the implications.

The size of the gift is also important when considering how substantial it is and whether the patient can afford this gift within their means. If you believe this gift is too extravagant for the patient to afford then the best thing to do would be to politely refuse it. The refusing of the gift is one of the main ethical issues, where the act of refusal may offend the person giving the gift and even disrupt the doctor-patient relationship which has clearly reached a certain level of respect and kindness. An excellent and important example of this can be learnt from the high profile case of psychiatrist Dr Peter Rowan who accepted monetary gifts of £50,000, £100,000 and a £1.2 million beneficiary from a woman under his care in London (MDDUS, 2010). When he tried to refuse these gifts she became angry and he felt obligated to take them. Due to the large amount of money, he made sure this was within her financial means by consulting her solicitor. Dr Peter Rowan has since been struck off due to the unclear reason why his patient left him £1.2 million in her will.

The concert tickets gift received by the doctor in the oncology clinic mentioned above clearly cost more than £100 and thus had to be declared. The doctor, not wanting to offend the patient, accepted the tickets and feeling it was not right to accept the tickets for her own use, organised a raffle for everybody in the oncology department to win the tickets. This, to me, seems like an appropriate and perfectly acceptable decision, which solves the ethical dilemmas of accepting the gift and not offending the patient, but not being accountable for using the gift as a bribe or to influence patient treatment by raffling the tickets for the whole department.

Kathryn Miller
3rd year Medical Student, KCL, London, UK
@Kathryn4365058

Prostate cancer survivorship: a new way forward

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Over 2 million people in England have a diagnosis of cancer. This is such a large problem, the Department of Health is spending £750 million on improving earlier diagnosis and prevention of cancer, yet at the same time, £20 billion of efficiency savings must be made. One arm of post-cancer care is survivorship. Survivorship care was initially developed in the USA 20 years ago, starting with breast cancer patients. Prostate cancer survivorship care has been lagging far behind.

Survivorship care involves risk profiling of patients, supported by community based teams and developing shared care/decision making. More often than not, they are fit and well, requiring PSA follow-up only. Yet no guidance relates to survivorship management.  

 

Cancer survivorship encompasses the “physical, psychosocial, and economic issues of cancer from diagnosis until the end of life.” There are significant concerns that current follow-up methods are unsuitable. Concerns regarding permanent physical, psychosocial, and economic effects of cancer treatment have been highlighted and give us good landmarks for survivorship care. These include monitoring for recurrence, metastases, side effects and coordination between secondary and primary care and impact on quality of life. If we examine what patients expect, this includes a full assessment of needs, discussion on side effects of treatment and a personalised care plan post-treatment. Patients also report not knowing who to contact for their care out of hours. Five key phases to survivorship care were identified: care via primary treatment from diagnosis, enable as rapid and full a recovery as possible, ensure recovery is sustained, manage side effects of treatment and monitor for recurrence or disease progression. As part of a National Cancer Survivorship Initiative, a recovery package was developed. This includes a holistic needs assessment and care planning at key points of the care pathway, a treatment summary, a cancer care review, a patient education and support event.

Based on these facts, we have developed a new survivorship model – this was set up as a National Cancer Survivorship Initiative. This programme was initially devised when it was identified specific areas of care were lacking in this cohort, when followed up on a clinic basis. It aims to address the holistic need of the survivorship cohort, and at the same time, allow monitoring for acute recurrence and follow-up care as well as community based follow-up and patient support.

Our Survivorship programme is for patients post-curative therapy for organ confined disease (surgery, external beam radiotherapy or brachytherapy). Patients are offered the option of entering into the survivorship programme and discharged from clinic (Figure 1). Inclusion criteria specify patients must be two years post-radical prostatectomy with an unrecordable PSA, or three years post-radiotherapy or brachytherapy with a stable PSA. We currently have over five hundred patients on this programme. The patients’ demographic, disease and treatment details are entered onto a password protected web based database. The IT programme allows patients to be monitored for recurrence via automatic extraction of PSA results from the hospital database. It is a bespoke database. Alerts are automatically generated if the PSA is above a previously set range. The clinical nurse specialist (CNS) running the programme will contact the responsible consultant once an alert is generated with the patient reviewed in clinic, if required. The CNS will also go through a ‘Distress Thermometer’ with patients on admission to the programme, to identify areas where the patient needs support, psychological, social etc. The specialist nurse would act as the patients’ keyworker, should they develop any side effects of treatment, or any recurrence.

At its initial inception, a focus group of patients was conducted, as part of participatory action research, to find out what they wanted as part of this programme – a user led system. Specifically, they mentioned a conference where they have access to health care professionals and specific topics covered including diet and exercise, nutrition, psychosexual counselling. This conference is held annually, with a range of healthcare professionals advising on identified patient issues e.g. psychological care, health promotion, research, and welfare. The conference allows patients to draw on their strengths and share experiences with each other. Topics such as identification of recurrence, long-term complications, rehabilitation services, quality-of-life issues, pain and symptom management and treatment of recurrent cancer are examples of areas covered. 

There are over 600 patients currently on the programme, a mixture of post-surgery, radiotherapy and brachytherapy. Of these patients, 29 have been referred back to clinic. When asked at the pilot conference if it was worth attending, 100% said yes. As a result of the initial focus group, comments have been made in support this programme.

Whilst this programme is currently only for patients post curative treatment, the next steps forward are to see if patients undergoing active surveillance or hormone therapy can be followed-up using this programme.

Further information:

National Cancer Survivorship Initiative

Worcestershire Prostate Cancer Survivorship Conference

Worcestershire Prostate Cancer Survivorship Programme

 

Goonewardene SS*, Persad R†,Nanton V‡, Young A‡, Makar A
*Homerton University Hospital, London, †North Bristol NHS Trust, ‡Warwick University, Worcestershire Acute Hospitals

Quality has no boundaries

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The new year has arrived bringing with it new expectations of success. It gives us the opportunity to reflect on 2013 and plan for the year ahead. We hope you enjoyed the new web journal www.bjui.org that we have introduced. It has certainly increased our full paper downloads each month which means that our readers do care. Thank you! Your loyalty makes the many hours of hard work – 24/7 – all worthwhile. We have an international team which allows someone, somewhere to be making constant improvements to the BJUI for your reading pleasure.

Many of our readers while congratulating us, commented that perhaps we had focussed on being of greater relevance to the younger generation. Imagine my surprise when at a recent Men’s Health meeting in London, my old chief came up to me for a discussion about the controversies of PSA testing following publication of the AUA guidelines [1] and a consensus statement from down under on blogs@BJUI [2]. He had read it all on the web much earlier than when these articles eventually make it to the print journal. Like him, many of our readers see and read an article or blog online but do not necessarily comment on it. As a new metric, we will start indicating the number of times an article is read in addition to the number of comments it receives.

At the BJUI we do not make New Years resolutions. It is much easier to act. During our editorial board meeting last October it became obvious that we were receiving high quality papers from all over the world. In this issue, we have the great pleasure of showcasing a superb article on circumcision from Uganda [3]. Men with or without HIV, which is highly prevalent in Africa, tend to heal well after circumcision. This does not appear to be affected by their CD4 counts. This is a large study, relevant to all urologists and I would urge you to read it and the accompanying editorial from Paul Hegarty [4].

This article also gave us the idea of highlighting the geographical location of the article of the month on the front cover. Another inspirational concept from Tet Yap our associate editor for design. More about that in coming editions.

Finally Maxine Sun is back with a SEER study showing that the extent of lymphadenectomy during radical nephrectomy in patients with nodal metastasis, does not affect survival. Like any database, missing entries may have confounded the results and it is critical from a scientific standpoint to understand the resultant bias [5]. For those wishing to learn health services research a good starting point is to read the Sun Blog on SEER at our web journal.

Here’s looking forward to interacting with you in 2014.

Prokar Dasgupta
Editor in Chief, BJUI

Guy’s Hospital, King’s Health Partners

References

  1. Ballentine Carter H. American Urological Association (AUA) Guideline on prostate cancer detection: process and rationale. BJU Int 2013; 112: 543–547
  2. Murphy D. The Melbourne Consensus Statement on Prostate Cancer Testing. blogs@BJUI. Available at: https://www.bjuinternational.com/bjui-blog/the-melbourne-consensus-statement-on-prostate-cancer-testing/. Accessed 20 November 2013
  3. Kigozi G, Musoke R, Kighoma N et al. Male circumcision wound healing in HIV-negative and HIV-positive men in Rakai, Uganda. BJU Int 2014; 113: 127–132
  4. Hegarty P. Circumcision – follow up or not? BJU Int 2014; 113: 2
  5. Sun M, Trinh Q-D, Bianchi M et al. Extent of lymphadenectomy does not improve the survival of patients with renal cell carcinoma and nodal metastases: biases associated with the handling of missing data. BJU Int 2014; 113: 36–42

Original publication of this editorial can be found at: BJU Int 2014; 113: 1. doi: 10.1111/bju.12575

Editorial: Too many men still undergo needless prostate biopsy

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Multiple studies have shown that only one in three or four men with a raised PSA level prove to have prostate cancer and many men suffer potentially life-threatening complications from transrectal prostate biopsy. There is an urgent need for better risk stratification of men with elevated PSA levels. Any such test should have a high negative predicative value (NPV; small number of significant cancers missed) but also a high positive predictive value (PPV; i.e. the yield would be high and there would be very few false positives) to diminish the number of unnecessary biopsies. Multiparametric MRI (mpMRI) of the prostate, especially with a stronger 3 T magnet, has been advocated for this purpose. The parameters refer to the separate MRI sequences used, typically at least three. Sequences can not only study the anatomy of the gland (standard T2-weighted MRI), but there is also a measure of the tissue cellularity (diffusion-weighted MRI), vascularity (dynamic contrast-enhanced MRI) or biochemistry (magnetic resonance spectroscopy). Initial data have shown promise but the changes seen on these various sequences can be subtle and interpretation is subjective. Naturally observer experience plays a large part but a standardised scoring system, the so called Prostate Imaging Reporting and Data System (PIRADS) system, has been proposed to improve reporting performance [1]. Each parameter is scored on a scale of 1–5 according to the likelihood of cancer. Scoring systems are always a compromise between the NPV and PPV, and so far there is no agreement where the threshold for each parameter should be set. In the original document, the authors proposed that a score of 4 or 5 signifies a high likelihood or almost certainty of cancer, whilst scores of 1 or 2 denote a high likelihood of benign tissue. A score of 3 is evens. The paper by Kuru et al. [2] shows a high NPV only when the threshold was set at the low level of 2 for each parameter. Predictably, at this threshold the PPV was extremely low, and therefore many men would still undergo unnecessary biopsy. Another similar paper advocated a mean threshold of 3, but even then the PPV was 38% with a NPV of 95% [3]. Both these papers are retrospective studies, in particular the MRI readings were done retrospectively. Nevertheless, the low PPV is disappointing. The results of prospective studies with multiple readers are keenly awaited and I hope that that these will find a higher PPV for mpMRI, and we can to move to an era when fewer men undergo needless prostate biopsy.

Uday Patel
St George’s Hospital, London, UK

Read the full article

References

  1. Barentsz JO, Richenberg J, Clements R et al. ESUR prostate MR guidelines 2012. Eur Radiol 2012; 22: 746–757
  2. Kuru T, Roethke M, Rieker P et al. Histology core-specific evaluation of the European Society of Urogenital Radiology (ESUR) standardised scoring system of multiparametric magnetic resonance imaging (mpMRI) of the prostate. BJU Int 2013; 112:1080–1087
  3. Portalez D, Mozer P, Cornud F et al. Validation of the European Society of Urogenital Radiology scoring system for prostate cancer diagnosis on multiparametric magnetic resonance imaging in a cohort of repeat biopsy patients. Eur Urol 2012; 62: 986–996

The Bengal Urological Society’s Golden Jubilee

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We recently celebrated the Bengal urological Society’s Golden jubilee!

Earlier known as the “Calcutta Urology Association”, the society was founded in the year 1963 and is the oldest urological society in India. My guess is that it is probably one of the oldest societies that aimed to establish a separate existence of urology. What’s your take on that?

It was a privilege to have Prof Prokar Dasgupta with us for this event. The demonstration of the robotic surgery by the master himself was exhilarating.

 


Dr Prokar Dasgupta, receiving the “Award of Excellence”

The feedback from the urological community and especially the residents has been phenomenal. I am sure that the light has been ignited in the minds. We are planning to take concrete steps to help serve our community better.  The idea of a “Reverse Movember” (shaving off our moustaches) for prostate cancer sounds exciting and will be great if I am able to implement it!

Amit Ghose

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