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Research on BPH and Prostate Cancer Takes Center Stage

Researchers confirm the importance of involving patients in BPH treatment decisions and discuss coverage of PSA testing

The Prostate Patient Outcomes Research Team (PORT) was funded by the Agency for Health Care Policy and Research (HS06336) to assess therapies for localized prostate cancer and benign prostatic hyperplasia (BPH). Prostate PORT researchers, led by John E. Wennberg, M.D., of Dartmouth College, recently published four studies, discussed below. Three of the studies demonstrate men's resilience in coping with the aftereffects of radical prostatectomy and the importance of involving patients in decisions to treat BPH; the fourth is an issue paper which discusses whether or not Medicare should reimburse physicians for PSA testing for early detection of prostate cancer, which is recommended annually by the American Cancer Society for men 50 years of age and older.

Fowler, F.J., Barry, M.J., Lu-Yao, G., and others (1995, June). "Effect of radical prostatectomy for prostate cancer on patient quality of life: Results from a Medicare survey." Urology 45(6), pp. 1007-1015.

Nearly one third (32 percent) of the Medicare patients who have undergone radical prostatectomy wear pads to deal with wetness, and 60 percent or more have become impotent. Yet many elderly patients are able to adapt to these problems, according to Prostate PORT researchers (also supported by AHCPR grant HS08397). On average, incontinence to the point of needing to wear pads bothered patients more than the loss of sexual function. Overall, postsurgical patients scored comparatively high on quality of life measures, reported feeling positive about the results of the surgery (81 percent), and would choose surgical treatment again (89 percent). Nonetheless, some patients were less positive about the surgery and its impact on their quality of life. These findings suggest that properly selected and prepared patients are willing to sacrifice some quality of life for the chance to be surgically cured of their cancer. They also reinforce the importance of individualized decisions about radical prostatectomy for prostate cancer, conclude the researchers. These findings are based on mail, telephone, and personal interviews with a national sample of 1,072 Medicare patients who underwent the surgery from 1988 through 1990.

Wagner, E.H., Barrett, P., Barry, M.J., and others (1995). "The effect of a shared decisionmaking program on rates of surgery for benign prostatic hyperplasia," and Barry, M.J., Fowler, F.J., Mulley, A.G., and others. "Patient reactions to a program designed to facilitate patient participation in treatment decisions for benign prostatic hyperplasia." Medical Care 33(8), pp. 765-770 and 771-782.

BPH is a nonmalignant but progressive condition that can cause obstruction of the urethra and chronic urinary symptoms or infections. Transurethral resection of the prostate (TURP) is sometimes necessary. Patients with BPH who are informed about the pros and cons of TURP versus watchful waiting for their condition may change their minds about surgery, according to a Prostate PORT pilot study (also supported by AHCPR grants HS08397 and HS06540). Patients with BPH in two HMOs were shown an interactive videodisc-based patient education program, The Shared Decisionmaking Program (SDP) for BPH, which was designed to help patients make an informed choice about whether to elect TURP or watchful waiting. Before viewing the SDP, about two-thirds of the men preferred watchful waiting. After viewing the program, this figure increased to 79 percent. Also, 27 percent of the men initially favoring surgery changed their minds compared with only 1 percent of those initially inclined to wait. The researchers conclude that educating patients and involving them in decisions about their care can have measurable impacts on therapeutic choices. A related Prostate PORT study showed that 421 patients in three urology practices (including the two HMOs noted above) reacted very positively to the videodisc program in 1989 and 1990. Patients rated the program as generally clear, informative, and balanced; 77 percent of patients were very positive and 16 percent were generally positive about the program's usefulness in making a treatment decision.

Barry, M.J., Fleming, C., Coley, C.M., and others (1995). "Should Medicare provide reimbursement for prostate-specific antigen testing for early detection of prostate cancer? Part I: Framing the debate." Urology 46(1), pp. 2-13.

This article by Prostate PORT researchers (also supported by AHCPR grant HS08397) is the first of a four-part policy analysis of whether or not Medicare should provide reimbursement for PSA testing for early detection of prostate cancer. This first article frames the debate and discusses the magnitude of the problem of prostate cancer among older men, describes the rationale for early detection and treatment, and outlines special issues in screening Medicare-age men. The researchers also discuss current conflicting recommendations on early detection of prostate cancer and review the basic biology and epidemiology of the condition. Finally, they discuss ongoing and planned randomized trials for the early detection and treatment of clinically localized prostate cancer. Future articles will review early detection strategies for prostate cancer; examine management strategies; and estimate the risks, benefits, and costs of an early detection program among older men.

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