BERKELEY, CA (UroToday.com) - The abstract by Lent, Baumbusch and Weber reminds us that the risk of malpractice lurks around every corner. Failure is possible and occurs even when it comes to basic steps directed towards detecting prostate cancer.
As long as the human factor is involved, mistakes will happen: errare humanum est. To minimize the risk of error, best practice guidelines provide guidance for many situations and may serve as a checklist, especially in times when stress, lack of time, or personal problems interfere with the attention and diligence necessary in patient care. Making clinical decisions on the basis of guidelines is an option although they have no legal binding character. But even though they may not be the ultimate answer to all questions about diagnosis and treatment for the individual patient, they provide guidance of how to approach the majority. Other important factors for making individual clinical decisions include personal prerequisites of the patient and experience of the doctor. Current evidence suggests that many urologists choose to trust their own expert opinions more than they trust guidelines. In a recently published survey on the management of testicular neoplasms in France, only 44 % of the patients with seminoma were treated according to the national guidelines.[1] When it came to non-seminoma, adherence to the guidelines was as low as 28%. Chamie and co-workers used the SEER database to look at the quality of care in high-grade non-muscle-invasive bladder cancer.[2] To minimize tumor recurrence and progression, the guidelines[3] recommend upper tract imaging, cytology, cystoscopy, BCG and perioperative mitomycin instillations. Only 15 % of the patients underwent the suggested surveillance cystoscopies and 3% received postoperative mitomycin instillations. No more than one person out of 5,627 obtained all five measures.
This team's article gives insight into the quality of prostate cancer screening in the German county of Northrhine-Westphalia. Approximately 13 200 new cases[4] are diagnosed per year. Within a six-year interval, the committee received 22 accusations of malpractice regarding urologists. They consented to 15 cases, which is on average 2.5 per year. In the PSA-range 4-10 ng/ml, positive prostate biopsies can be expected in 47 %. Therefore, to diagnose 13 200 men with prostate cancer, 28 100 men in the PSA-range 4-10 ng/ml will have to be biopsied. With 2,5 annual misinterpretations of PSA levels within this interval in Northrhine-Westphalia, 0.009 % of the patients are subject to treatment error. This very low number has to be interpreted with care since not all treatment failures are reported. Nevertheless, it appears that prostate cancer screening by urologists in Northrhine-Westphalia is of high quality.
References:
- Culine S, Hoppe S, Hennequin C, Saves M, Mottet N and FRANCIM network. Management of testicular neoplasms in France and compliance with national guidelines. JCO 2010; 28(15) Suppl.: 4580.
- Chamie K, Saigal C, Hanley J, Konety B, Litwin M. Quality of care for patients with high-grade non-muscle-invasive bladder cancer. J Urol 2010; 183(4) Suppl.: 1475.
- Guidelines from: American Association of Urology, European Association of Urology, National Comprehensive Cancer Network.
- Batzler WU, Bertram H, Heidinger O, Kajüter H, Krieg V, Mattauch V. Epidemiologisches Krebsregister NRW, Report 2011 mit Datenbericht 2009. Münster 2011. P. 76. Accessed online 27.08.2012 at URL: http://www.krebsregister.nrw.de/fileadmin/user_upload/dokumente/veroeffentlichungen/Report_2201/EKR_NRW_Report_2011_Internet.pdf
Written by:
Stefan Buntrock, MD, FEBU as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
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Criteria for errors in prostate-specific antigen diagnostics - Abstract
