Prostate cancer screening.

Prostate cancer is the most common cancer and the second leading cause of cancer-related deaths in American men. Although the use of the prostate-specific antigen (PSA) test for prostate cancer screening since the 1990s has led to increased early diagnoses, the most recent studies are in conflict about the risks and benefits of routine prostate cancer screening. Recently, evidence has emerged to support the use of the PSA test to lower mortality, but there is still concern that over-diagnosis may lead to over-treatment of cancers that would not significantly affect patients' health for several years. This article describes the results of important recent prostate cancer screening trials, the National Comprehensive Cancer Network and American Cancer Society screening guidelines, and discusses the implications for clinical practice.

Low utility of dobutamine stress echocardiograms in the preoperative evaluation of patients scheduled for noncardiac surgery.

UNLABELLED: In this study, we examined the utility of preoperative dobutamine stress echocardiograms (DSE) obtained for 85 patients in accordance with guidelines published by the American College of Cardiology (ACC) and the American Heart Association (AHA). The medical record of each patient was reviewed to identify the clinical criteria that indicated the need for a DSE, the DSE results, therapeutic interventions rendered as a result of the DSE, and any perioperative cardiac morbidity. The DSE was positive for inducible ischemia in 4 patients (4.7%), negative in 74 (87.1%), and nondiagnostic in 7 (8.2%). DSEs that were obtained for 48 patients because of a history of diabetes mellitus, mild angina, or "minor clinical predictors" produced only negative results. Of the four patients with positive DSE results, three underwent coronary angiography, and one of those three underwent bypass grafting before surgery. An additional 29 patients received a preoperative DSE but were excluded from the study because the criteria for ordering the DSE did not meet the ACC/AHA guidelines. No patient had any perioperative morbidity related to myocardial ischemia. The total patient charge for the 85 DSEs obtained at our institution was US$104,635. Use of the ACC/AHA guidelines for preoperative DSEs does not appear to be cost-effective. However, the current algorithm could be significantly improved by altering the criteria for obtaining preoperative DSEs. IMPLICATIONS: This study was a retrospective review of 85 patient charts that found a low cost-effectiveness of using American College of Cardiology/American Heart Association guidelines for obtaining preoperative dobutamine stress echocardiograms. Suggested modifications of these guidelines should improve their specificity with no loss in sensitivity.