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FISHing for genes
THE LANCET
FlSHing for genes These human chromosomes have been tagged with fluorescent markers in the FISH (fluotechnique rescence in-situ hybridisation) to study the genes therein. It is one of the images on show at an exhibition that looks a t issues of genetic testing. Genetic Choices? is intended to provoke c debate by covering E concerns such as the benefits and disf advantages of testv: ing, access to personal genetic information, health insurance, and the implications of being a carrier. The exhibition will include hands-on displays to hear from individuals who have a genetic disorder, and visitors will be able to access information and opinions on genetic tests. Genetic Choices? runs until April 13, 1997, at the Science Museum, London.
Prostate queries Questions and Uncertainties about Prostate Cancer Edated by W B Peelzng. Oxford: Blackwell Scaence. 1996. Pp 31 1. K39.50. ISBN 0-86542-965-0.
mong the ongoing controversies in medicine today, prostate cancer management probably ranks among the highest. Apart from the management of metastatic disease, few randomised studies have been done, leading to different opinions based on insufficient data. W B Peeling has brought together a collection of well-written views on these issues. The most pressing questions addressed in this book are-is routine screening appropriate; how should prostate-specific antigen (PSA) be used; what constitutes adequate staging; what is the role of lymphadenectomy; which is the best local therapy; what is the role for postoperative radiation therapy; what is the best timing and type of hormone therapy; and what should be done for a rising PSA? The chapter on PSA testing is particularly informative in light of the various attempts at improvement that have been made. But a question not included is whether PSA should simply be abandoned in favour of routine random
A
580
biopsy and more discriminate selection of patients for treatment. The poor results for staging by use of routine computed tomography, magnetic-resonance imaging and bone scan is a good justification for why we, among others, have almost eliminated regular application of these tests. By contrast, the discussion on transrectal ultrasonography provides a justification for the continued use of this technique in diagnosis. The status of new approaches to predicting outcome is summarised well, and the chapters on hormone therapy are well written and informative. However, the main drawback of Questions and Uncertainties about Prostate Cancer is that it could have
been much shorter if it had excluded extensive reviews on topics that do not really contribute to a good understanding of the controversial questions and the interim solutions. Also, in some areas, it is already out of date. For example, the description of radical prostatectomy is really about “how to”, rather than “when to”; it does not address the questions of whether anaes-
thesia can be modified, hospital stay can be decreased, lymphadenectomy or blood donation is really necessary. Nor does it tackle whether perineal is better than a retropubic approach, and it ignores changes already taking place in the USA. For example, whereas average inpatient stay used to be 10 days, the average length of stay is now 4 days, and we routinely send patients home the day after surgery. In one chapter, the preliminary findings of neoadjuvant-hormone therapy before radical prostatectomy are discussed. However, at the 1996 American Urological Association meeting, 2-year follow-up revealed no difference in the PSArecurrence rate whether neoadjuvant hormones were used or not, which raises doubt over the potential value of this approach. Also, the chapter on pelvic lymphadenectomy ignores the combined use of PSA, clinical stage, and tumour grade to predict lymph-node metastases, and thereby select patients with significant risk to warrant the risk of the operation. In our experience, laparoscopic rymphadenectomy has been almost eliminated because the advantage of the procedure was short hospital stay and we have achieved that with open surgery by modifying anaesthesia. I had other concerns about content. The chapter on induction and growth of prostate cancer is a well-written overview of this topic but does not fit into the theme of the book and some of the information is duplicated in a separate discussion of predicting which tumours are dangerous. While the shortcomings of screening are described there is no clear reference to the proargument for screening. At least in the USA, a more active position is common, meaning that in the absence of good data, more is better than less, and most people endorse screening. In the light of the risks and benefits, and the unlikely appearance of data from a randomised trial for at least 15 years, an approach to screening not addressed is to ask for and provide informed consent, thereby ensuring that patients have at least some understanding of this uncertainty and then they can help decide for themselves. Despite the deficiencies, Questions and Uncertainties about Prostate Cancer contains useful information and is a helpful resource for understanding many of the controversies in this area.
Gerald Chodak Louis A Weiss Memorial Hospital, 4646 North Marine Drive, Chicago, IL 60640, USA
-
Vo1349 February 22,1997
FlSHing for genes These human chromosomes have been tagged with fluorescent markers in the FISH (fluotechnique rescence in-situ hybridisation) to study the genes therein. It is one of the images on show at an exhibition that looks a t issues of genetic testing. Genetic Choices? is intended to provoke c debate by covering E concerns such as the benefits and disf advantages of testv: ing, access to personal genetic information, health insurance, and the implications of being a carrier. The exhibition will include hands-on displays to hear from individuals who have a genetic disorder, and visitors will be able to access information and opinions on genetic tests. Genetic Choices? runs until April 13, 1997, at the Science Museum, London.
Prostate queries Questions and Uncertainties about Prostate Cancer Edated by W B Peelzng. Oxford: Blackwell Scaence. 1996. Pp 31 1. K39.50. ISBN 0-86542-965-0.
mong the ongoing controversies in medicine today, prostate cancer management probably ranks among the highest. Apart from the management of metastatic disease, few randomised studies have been done, leading to different opinions based on insufficient data. W B Peeling has brought together a collection of well-written views on these issues. The most pressing questions addressed in this book are-is routine screening appropriate; how should prostate-specific antigen (PSA) be used; what constitutes adequate staging; what is the role of lymphadenectomy; which is the best local therapy; what is the role for postoperative radiation therapy; what is the best timing and type of hormone therapy; and what should be done for a rising PSA? The chapter on PSA testing is particularly informative in light of the various attempts at improvement that have been made. But a question not included is whether PSA should simply be abandoned in favour of routine random
A
580
biopsy and more discriminate selection of patients for treatment. The poor results for staging by use of routine computed tomography, magnetic-resonance imaging and bone scan is a good justification for why we, among others, have almost eliminated regular application of these tests. By contrast, the discussion on transrectal ultrasonography provides a justification for the continued use of this technique in diagnosis. The status of new approaches to predicting outcome is summarised well, and the chapters on hormone therapy are well written and informative. However, the main drawback of Questions and Uncertainties about Prostate Cancer is that it could have
been much shorter if it had excluded extensive reviews on topics that do not really contribute to a good understanding of the controversial questions and the interim solutions. Also, in some areas, it is already out of date. For example, the description of radical prostatectomy is really about “how to”, rather than “when to”; it does not address the questions of whether anaes-
thesia can be modified, hospital stay can be decreased, lymphadenectomy or blood donation is really necessary. Nor does it tackle whether perineal is better than a retropubic approach, and it ignores changes already taking place in the USA. For example, whereas average inpatient stay used to be 10 days, the average length of stay is now 4 days, and we routinely send patients home the day after surgery. In one chapter, the preliminary findings of neoadjuvant-hormone therapy before radical prostatectomy are discussed. However, at the 1996 American Urological Association meeting, 2-year follow-up revealed no difference in the PSArecurrence rate whether neoadjuvant hormones were used or not, which raises doubt over the potential value of this approach. Also, the chapter on pelvic lymphadenectomy ignores the combined use of PSA, clinical stage, and tumour grade to predict lymph-node metastases, and thereby select patients with significant risk to warrant the risk of the operation. In our experience, laparoscopic rymphadenectomy has been almost eliminated because the advantage of the procedure was short hospital stay and we have achieved that with open surgery by modifying anaesthesia. I had other concerns about content. The chapter on induction and growth of prostate cancer is a well-written overview of this topic but does not fit into the theme of the book and some of the information is duplicated in a separate discussion of predicting which tumours are dangerous. While the shortcomings of screening are described there is no clear reference to the proargument for screening. At least in the USA, a more active position is common, meaning that in the absence of good data, more is better than less, and most people endorse screening. In the light of the risks and benefits, and the unlikely appearance of data from a randomised trial for at least 15 years, an approach to screening not addressed is to ask for and provide informed consent, thereby ensuring that patients have at least some understanding of this uncertainty and then they can help decide for themselves. Despite the deficiencies, Questions and Uncertainties about Prostate Cancer contains useful information and is a helpful resource for understanding many of the controversies in this area.
Gerald Chodak Louis A Weiss Memorial Hospital, 4646 North Marine Drive, Chicago, IL 60640, USA
-
Vo1349 February 22,1997