[Practice guideline 'Prostate cancer: diagnosis and treatment']. / Richtlijn 'Prostaatcarcinoom: diagnostiek en behandeling'.

--A national, multidisciplinary practice guideline was developed concerning diagnosis and treatment of patients with prostate cancer. Because of the lack of sufficient scientific evidence at this moment no practice guideline on screening is included. --The diagnosis of prostate cancer is made by transrectal ultrasound-guided prostate biopsies. The Gleason score is used for histological grading. --In localized prostate cancer and comorbidity 'active surveillance' is advised if the life expectancy is < 10 years. In healthy patients radical prostatectomy, external and internal radiotherapy are equivalent treatment options. The final decision is made after the patient has received adequate counselling. --In locally advanced prostate cancer in a patient with a life expectancy > or = 10 years external beam radiotherapy is the preferred treatment whether or not in combination with hormonal therapy. --In locally recurring prostate cancer following radical prostatectomy and prostate-specific antigen (PSA) < 1.0 ng/ml salvage radiotherapy can be advised. Recurrence following external beam radiotherapy may be treated by salvage radical prostatectomy or brachytherapy in selected cases. --In metastatic prostate cancer androgen deprivation therapy is advised, i.e. surgical castration, luteinizing hormone-releasing hormone (LH-RH) analogues, or parenteral estrogens. --In hormone resistant prostate cancer palliative treatment of painful metastases is advised, e.g. painkillers, local radiotherapy, or radionuclides. The role of docetaxel-based chemotherapy should be discussed. --During follow-up PSA is determined; digital rectal examination and imaging are performed whenever indicated.

Signalising psychosocial problems in cancer care :the structural use of a short psychosocial checklist during medical or nursing visits.

OBJECTIVE: In this summary of literature, we evaluated 16 studies with respect to recognition and screening for psychosocial problems of cancer patients during nursing or medical visits, and with respect to the effects of providing quality of life information during these visits. METHODS: A review of the literature was conducted. To obtain the relevant literature, a search was made of two databases: Medline and Nursing and Allied Health Literature. The literature from the last 12 years - from 1993 till 2004 - was selected. RESULTS: The results show that in a number of studies a gap is demonstrated between the presence of cancer patients' psychosocial problems and health care providers' ability to signalise these problems adequately. The outcomes of these studies further show that the use of a psychosocial checklist is helpful in screening and communicating psychosocial problems, and that supplying information about quality of life facilitates provider-patient communication about these issues. CONCLUSION: None of the studies, however, provides extensive insight into the feasibility of a psychosocial checklist in daily oncology practice. Implementation projects have to be conducted focussing on conditions that block or facilitate the use of a psychosocial checklist in daily practice. PRACTICE IMPLICATIONS: By monitoring blocking and facilitating conditions strictly and, if necessary, by adjusting them, we can create guidelines to make the use of a psychosocial checklist feasible.

Psychosocial factors and the course of cervical intra-epithelial neoplasia: a prospective study.

OBJECTIVE: To investigate the influence of psychosocial factors on the course of cervical intra-epithelial neoplasia (CIN). METHODS: A group of 93 patients with CIN 1 or 2 was followed for 2.25 years by half-yearly colposcopy and cytology. Negatively-rated life events, social support, and coping style were studied in relation to distress during follow-up and in relation to time till progression and regression of CIN. Human papillomavirus (HPV) infection was controlled for as well as sick role bias caused by suspicion of having cervical cancer and distress due to the abnormal cervical smear. RESULTS: During follow-up, progression was found in 20 patients (22%), stable disease in 22 patients (24%), and regression in 51 patients (55%). Negatively-rated life events and lack of social support predicted distress longitudinally. No association was found between progression or regression of CIN and negatively-rated life events, lack of social support, coping style, and distress. CONCLUSION: We found no evidence that psychosocial factors influence the course of CIN.

Positive and negative affect after diagnosis of advanced cancer.

Anxiety and depression are studied thoroughly in patients with advanced cancer. However, little is known about the nature of mood disorders in this stage of the disease. We studied positive and negative affect in patients who have had a diagnosis of advanced cancer, and examined how these are related to anxiety and depression, and to other patient and care factors. One hundred and five patients filled out a written questionnaire and were interviewed personally. The PANAS positive affect scores were lower than those in the general population, but the negative affect scores were fairly similar. We found a rather low prevalence of depression (13%) and anxiety (8%) as measured by the HADS. The emotional problems patients mentioned most frequently were anxiety about metastases (26%), the unpredictability of the future (18%) and anxiety about physical suffering (15%). Both positive and negative affect were most strongly related to patient's sense of meaning and peace. We conclude that distinguishing positive and negative affect enhances the understanding of psychological distress of patients with advanced cancer, that seems to be mainly caused by low levels of positive affect. Several theories are discussed to explain this finding, that may contribute to efforts to improve care for these patients.

A prospective longitudinal study comparing the impact of external radiation therapy with radical prostatectomy on health related quality of life (HRQOL) in prostate cancer patients.

BACKGROUND: The objective of the present study is to compare the impact on the general and disease-specific health related quality of life (HRQOL) of external radiation therapy (ERT) with radical prostatectomy (RP) in patients with localized prostate cancer, and to explore which factors, and to what extent, contribute to the assessed changes in HRQOL. METHODS: One hundred and thirty eight patients participated in this prospective longitudinal study. They completed before treatment (T0) and after 12 months (T1) a questionnaire constructed of validated instruments, measuring HRQOL and several psychosocial factors (PF). Among other things, multiple regression analyses including all baseline characteristics, HRQOL and PF were executed in order to meet the objectives. RESULTS: RP patients showed significantly more improvement in their emotional function, while they reported more incontinence and a worse sexual function. There was significantly more improvement in the overall HRQOL of ERT patients, while the changes in the gastrointestinal function of these patients were significantly worse. Only the differences with respect to incontinence can be attributed to the treatment itself. Almost all HRQOL change scores are primarily influenced by their own baseline score. The influence of other factors, like age, socioeconomic status, and several PF, is limited. CONCLUSIONS: The impact on HRQOL of ERT is similar to that of RP, except for incontinence. RP patients suffer more from incontinence than ERT patients. Changes in the assessed HRQOL are mainly influenced by the pre-treatment HRQOL scores.

Health-related quality of life and psychosocial factors in patients with prostate cancer scheduled for radical prostatectomy or external radiation therapy.

OBJECTIVE: To assess whether baseline health-related quality of life (HRQOL) and psychosocial profiles differ in patients with prostate cancer scheduled for radical prostatectomy (RP) or external radiation therapy (ERT), as there is evidence that HRQOL is influenced by psychosocial factors (PFs), so that any variation at baseline should be considered when comparing the effect of therapy on HRQOL. PATIENTS AND METHODS: Before receiving therapy, HRQOL and PFs were assessed in 65 patients scheduled for RP and in 73 scheduled for ERT. To measure HRQOL (generic and disease-specific) and PFs, an extended questionnaire was constructed, using validated and standardized instruments. Clinical data were collected from patients' medical records. Comparisons adjusted for age and socio-economic status (SES) were analysed using Student's t-test and univariate analyses of variance and covariance. RESULTS: Patients scheduled for ERT were 7.9 years older and had a lower SES (both P < 0.001), more often had stage T3 and T4 disease, had poorer histopathological differentiation and higher levels of prostate-specific antigen (all P < 0.01). They also reported a worse physical, role, cognitive and social function, more fatigue, more pain, a lower overall HRQOL and worse sexual function than patients scheduled for RP. There were no differences in urinary and bowel function, nor in the PFs assessed. CONCLUSION: The baseline HRQOL profile of patients scheduled for RP is better than in those scheduled for ERT. These results are in line with those from the few other studies on this subject. Knowing the impact of RP and ERT on HRQOL should therefore be based mainly on longitudinal studies including baseline measures, the analyses of which should be adjusted for age and SES. In the present small study, baseline PFs did not differ between the treatments.

Determinants of doctor consultation for micturition problems in an elderly male population.

OBJECTIVE: To study which factors influence doctor consultation when a subject has micturition problems. METHODS: Postal questionnaire in an open population of older men (n = 1,695), followed by investigations in 10 general practices, including uroflowmetry. RESULTS: 25% of the men had micturition problems, of which 10-30% presented their symptoms to a doctor. Almost 60% experienced an influence of their micturition habits on activities of daily living. More than 85% of the men were not able to compare their micturition pattern with others. In multiple logistic regression, presentation to a doctor was independently associated with obstructive symptoms, dysuria, men defining their situation as a complaint, depressive mood, more frequent sexual desire and smoking. Many other factors which might play a role in diagnosis and timing of treatment were not found to influence consultation. CONCLUSION: Most men deal with micturition problems without consulting, although symptoms have a substantial impact on daily life. Consultation was associated with symptoms, psychological factors and smoking.

Perspectives of reproductive health.

This issue of Patient Education and Counseling is dedicated to reproductive health. The main focus is infertility as it is experienced in different of our world. In western societies, medical breakthroughs give couples with fertility problems a good chance to have a child. However, in many developing societies adequate medical treatment is only available for the upper classes, and many women keep going to traditional healers. In addition, the social consequences of childlessness are much greater than in western societies. Another focus of this issue is negative experiences regarding pregnancy. A very distressing experience is late pregnancy loss. Late pregnancy loss is different from infertility with respect to the tangibility of an object of grief, though it may also result in permanent childlessness. Other aspects of negative pregnancy experiences are exceptional physical reactions and recurrent induced abortions. Furthermore, two other elements of reproductive health are addressed in this issue: STD among female adolescents and gender aspects of gene technology. Finally, the ramifications of these various aspects of reproductive health on education and counseling are discussed.

Contraceptive use and attitudes in reunified Germany.

Contraceptive use and attitudes were assessed in a random sample of 1064 German women. The majority (76%) of the sexually active, fertile women who were not pregnant and did not wish to get pregnant at the time of the survey were using very reliable contraceptive methods, namely oral contraceptives (OCs), intrauterine devices (IUDs) or sterilization. Comparison with a previous survey showed that contraceptive practice in West Germany had improved considerably since 1985. Attitudes towards the most reliable methods available (OCs, IUDs and sterilization) were found to be ambivalent. Perceived side effects and health risks were a particular matter of concern to the respondents. Although most respondents (88%) recognized that condoms prevent the transmission of AIDS, 66% of those who had occasional sexual partners did not use barrier methods. It is concluded that German contraceptive practice is reasonably effective and that if attitudes were to become more realistic the level of effectiveness could even be raised.

PIP: The sample for this 1992 survey of contraceptive use and attitudes was obtained by random-walk sampling, whereby field workers from a survey agency that collaborated in carrying out the study followed designated routes throughout the country, starting from 257 predetermined locations. They identified subjects 15-45 years old by visiting their homes and inviting the woman in each household to participate in the study. Of the 1064 women surveyed, 75.7% were defined as being exposed to the risk of conception; 3.8% stated they were infertile, 4.2% were currently pregnant, 4.0% intended to get pregnant, and 15.6% were not sexually active. The barrier methods used comprised condoms (10.4%), diaphragms (0.9%), spermicides (0.6%), and combinations of condoms and spermicides (0.4%), of diaphragms and spermicides (0.1%), and of diaphragms and condoms (0.2%). Although most respondents (88%) recognized that condoms prevent the transmission of AIDS, 66% of those who had occasional sexual partners did not use barrier methods. 75.7% of exposed German women used reliable methods, namely OCs, IUDs, and sterilization. Women from what had been East Germany cited the common reasons mentioned for using contraceptives as often as did women from what had been West Germany (p 0.05), except for AIDS and sexually transmitted disease prevention (1.1% and 5.8%, respectively, p 0.05) and alleviation of skin disorders (2.3% and 12.5%, respectively, p 0.01). Information on contraception was obtained mainly from gynecologists (67.7%) and friends (30.9%). Comparison with a previous survey showed that contraceptive practice in the former West Germany had improved considerably since 1985. Attitudes towards the most reliable methods available (OCs, IUDs and sterilization) were found to be ambivalent. Perceived side effects and health risks were a particular matter of concern to the respondents. Certain disadvantages of OCs and IUDs were less frequently perceived by women from the former East Germany than by women from the former West Germany, whereas "East German" women were more frequently of the opinion that sterilization was a major and risky operation. German contraceptive practice is reasonably effective, and if attitudes were to become more realistic the level of effectiveness could even be raised.

Effectiveness of sex education provided to adolescents.

A literature review was conducted to investigate the effects of sexuality and birth control education on knowledge and attitude with regard to contraception use by adolescents in Western countries. The findings showed that sex education increased knowledge about sexuality and birth control. In many cases there was also a change in attitude with adolescents assuming a more liberal and tolerant attitude towards sexuality. Virtually no educational programme showed any influence on communication skills, assertiveness or skills with regard to contraception use. The sex education courses appeared to have no impact on sexual behaviour, such as intercourse. A few studies demonstrated that adolescents' intention to use contraception in the future was strengthened. Most studies found the education provided had a positive effect on contraception use, especially those programmes which explicitly integrated the desired behaviour into the educational course. A number of factors are discussed that influence the effect of sex and birth control education.

Contraception in The Netherlands: the low abortion rate explained.

This article gives a review of the main factors that are related to the low abortion rate in the Netherlands. Attention is payed to figures on abortion and the use of contraceptive methods since the beginning of the 1960s up to the end of the 1980s. The strong acceptance of family planning was influenced by changing values regarding sexuality and the family, the transition from an agricultural to a modern industrial society, rapid economic growth, declining influence of the churches on daily life, introduction of modern mass media and the increased general educational level. The introduction of modern contraceptives (mainly the pill and contraceptive sterilization) was stimulated by a strong voluntary family planning movement, fear for overpopulation, a positive role of GPs, and the public health insurance system. A reduction of unwanted pregnancies has been accomplished through successful strategies for the prevention of teenage pregnancy (including sex education, open discussions on sexuality in mass media, educational campaigns and low barrier services) as well as through wide acceptance of sterilization. The Dutch experience with family planning shows the following characteristics: a strong wish to reduce reliance on abortion, ongoing sexual and contraceptive education related to the actual experiences of the target groups, and low barrier family planning services.

PIP: People in the Netherlands consider unplanned pregnancy to be a large problem that society and decision-makers should and do seriously address. The abortion rate fluctuates between 5 to 7/1000 women of reproductive age, the lowest abortion rate in the world. Between 1965 and 1975, a shift from a largely agricultural society to an industrial society, rapid economic growth and the establishment of a welfare state, a reduced influence of the church in public and personal life, introduction of mass media, and a rapid increase in the educational level of both men and women brought about a rapid change in traditional values and family relations in the Netherlands. These changes and the introduction of modern contraception effected a breakthrough in family planning and sexual morality. Factors facilitating the rapid transition to a contraceptive society in the Netherlands were a voluntary family planning movement, fear of overpopulation, role of general practitioners in providing family planning services, and inclusion of family planning in the national public health insurance system. Acceptance of contraception preceded liberalization of abortion. Society accepts abortion as only a last resort. The sexual sterilization rate is higher than that in other European countries (25% vs. 0-23%). Special family planning programs in the Netherlands target groups at risk of unwanted pregnancy, particularly teenage pregnancy. Almost all secondary schools and about 50% of primary schools address sexuality and contraception. Sex education has largely been integrated in general health education programs. The mass media address adolescent sexuality and preventive behavior. Very large scale, nonmoralistic, public education campaigns that are positive towards teenage sexual behavior appear to be successful. Teens have wide access to contraceptive services through general practitioners who maintain confidentiality and do not require a vaginal exam and through subsidized family planning clinics.

Sexuality, sexual behaviour and contraception in East Germany.

Social factors may influence sexual health and its related behaviour. The political changes in East Germany have revealed a positive attitude towards sexuality and the use of family planning methods. A study on sexual behaviour and the use of contraceptives was undertaken recently, at the end of the old regime and the beginning of the new one. The survey was performed among 3103 male and female respondents (pupils, students and workers) of between 16 and 48 years of age. The results show a decreased number of stable partner relationships among young people, however, love and sexuality are considered to be central values. Before the age of 19 years, the majority of girls (80%) and boys (68%) had had sexual intercourse for the first time, a rate which has not changed during the last decade. There is a tendency to postpone having a first child. Modern contraception is widely accepted and used. There is a growing number of condom users, however, the pill is still the most popular method. Family planning is much more advanced than in the other countries of Eastern Europe. Sex education and counselling should sustain this situation.

PIP: In 1990, the Central Institute for Youth Research in Leipzig, Germany, conducted the Partner Study III which consisted of 3103 pupils, students, and factory workers in the former East Germany, 16-48 years old, to determine society's influence on partner relationships, sexuality, sexual behavior, and family planning use. Just 25% of 16-year-old males and 50% of 16 year-old-females had a stable partner relationship compared to 75% and 93%, respectively, for 16-year-olds in earlier studies. Almost everyone (99%) had premarital sexual intercourse. Mean age at first intercourse was 17, which usually occurred in a stable partnership (77% of males and 85% of females). 67% of 16-18 year old couples had agreed on contraception, especially oral contraceptives (OCs) and condoms (75% and 32%, respectively), before first intercourse. Most respondents considered love and sexuality to be central aspects of their lives. Respondents had sexual intercourse 8-9 days/month. Most women (91%) had had a recent orgasm. Most people wanted to marry, but later than they did previously, and to have children (87% and 99%, respectively). Yet, many East Germans were delaying childbearing. 99% favored contraception. Most people considered contraception to be the responsibility of both men and women. Acceptance of contraception did not include acceptance of abortion as a birth control method. Yet, few wanted to make the liberal abortion law more restrictive. The most commonly used contraceptive methods were OCs (66%) and condoms (62% vs. 35% in 1980). Overall, the sample had a good knowledge of contraceptive methods. More than 90% favored OCs. More than 80% accepted the condom. They considered it to be morally sound to carry a condom due to the threat of AIDS. Yet, few used a condom for each act of coitus. Safe contraception was a prerequisite for sexual intercourse for 79% of youth. Youth in East Germany tended to have a serious attitude of responsibility towards one's partner, contraception, and sexuality.

A study on the use of medication for climacteric complaints in western Europe--II.

Samples of about 300 women aged 40-69 were interviewed in Denmark and the Netherlands about consultations with a physician for climacteric complaints, awareness regarding the menopause and hormone replacement therapy (HRT), and use of medication. Twenty percent of Danish and 13% of Dutch respondents had consulted a physician. Fifty percent of Danish and 16% of Dutch respondents were informed about the menopause, and 46% of Danish and 10% of Dutch respondents were informed about HRT, the mass media being the most important information source. In Denmark and the Netherlands HRT use rates were 12% and 4%, respectively, those for non-hormonal treatment being 6% and 2%, and for tranquillizers 11% and 7%. Pooling of the data with those from a similar study conducted in Italy, the United Kingdom, West Germany and France [6] revealed that consultation for climacteric complaints was a universal phenomenon in all six countries which correlated mainly with perimenopausal status. Awareness of the menopause and HRT, and actual use of HRT were predominantly associated with the individual countries. These findings suggest that HRT prescription and use for climacteric complaints depend greatly on country-specific reservations about HRT among both physicians and women. Surprisingly, these appeared more prevalent in the countries where GPs played a predominant role in climacteric counselling.

Psychosocial aspects of in vitro fertilization.

There is growing recognition of the existence of an interaction between the psychosocial status of women and their (in)fertility. This has prompted study of the psychosocial aspects of in vitro fertilization (IVF). Following a literature survey, a psychosocial questionnaire was constructed using existing tests and a specific IVF attitude questionnaire was developed. This questionnaire was completed by 150 new IVF women who were participating in a multicenter study. The newly-developed specific IVF questionnaire appeared to be reliable and valid, although women had a tendency to give socially desirable answers. The results indicate that IVF women feel more anxious (State-Trait Anxiety Index) than a normal population, but do not express more emotional complaints (Hopkins Symptoms Checklist). Comparison of the answers concerning the situation before and after IVF treatment revealed that treatment outcome has no influence on attitude towards IVF. After treatment, the women's state of anxiety was unchanged, while the quality of couples' relationships was enhanced. A possible influence exerted by psychosocial factors on the chances of achieving pregnancy with IVF could not be confirmed. Several methodological aspects of the study are discussed to explain the results.

Contraceptive use and attitudes in Great Britain.

In order to update current knowledge on contraceptive use and attitudes in Great Britain (i.e. England, Scotland and Wales), a survey was conducted among 1753 randomly selected British women aged 15-45. Replies were received from 967 women (55.2%). Seventy-three percent (73%) of fertile, sexually active women who wished to avoid pregnancy were using reliable methods of contraception, viz. oral contraceptives (OCs), intrauterine devices (IUDs) or sterilization. However, it was found that adolescents and women over 40 who wished to avoid pregnancy were, nevertheless, especially likely not to be using any contraceptive method at all. The women surveyed were concerned about weight gain, cardiovascular and cancer risks associated with OC use, and infection and infertility risks associated with IUD use. Sixty percent (60%) perceived sterilization as a major and risky surgical operation. It was concluded that contraceptive practice in Britain had not improved greatly in recent years. The latest scientific findings regarding the true advantages and disadvantages of OCs, IUDs and sterilization, therefore, need to be brought to the attention of the lay public more effectively. Special efforts need to be directed towards providing adolescents and women over 40 with proper information. Physicians and the mass media could play a considerable role in this respect.