- Email: [email protected]
Pain during prostate biopsy
COMMENTARY
Moreover new targets have been identified9,13 for a disease sometimes seen to be languishing in a therapeutic desert with only occasional watering holes. However, our ideas on tackling the genetic basis of cerebrovascular disease clearly need constant revisiting. I have received honoraria for lecturing in industry-sponsored meetings and have received industry funding for attending national and international meetings. I have received research grants from pharmaceutical companies. I have been a paid consultant to the biotech industry.
Pankaj Sharma Department of Cellular and Molecular Neuroscience and Acute Stroke Unit, Hammersmith Hospitals & Imperial College, London W6 8RF, UK (e-mail: [email protected]) 1 2
3
4
5
6
7
8
9
10
11
12
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Liao D, Myers R, Hunt S, et al. Familial history of stroke and stroke risk: the Family Heart Study. Stroke 1997; 28: 1908–12. Joutel A, Corpechot C, Ducros A, et al. Notch3 mutations in CADASIL, a hereditary adult-onset condition causing stroke and dementia. Nature 1996; 383: 707–10. Goto Y, Horai S, Matsuoka T, et al. Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS): a correlation study of the clinical features and mitochondrial DNA mutation. Neurology 1992; 42: 545–50. Palsdottir A, Abrahamson M, Thorsteinsson L, et al. Mutation in cystatin C gene causes hereditary brain haemorrhage. Lancet 1988; 2: 603–04. Onda H, Kasuya H, Yoneyama T, et al. Genomewide-linkage and haplotype-association studies map intracranial aneurysm to chromosome 7q11. Am J Hum Genet 2001; 69: 804–19. Laberge-le Couteulx S, Jung HH, Labauge P, M et al. Truncating mutations in CCM1, encoding KRIT1, cause hereditary cavernous angiomas. Nat Genet 1999; 23: 189–93. Levy E, Carman MD, Fernandez-Madrid IJ, et al. Mutation of the Alzheimer’s disease amyloid gene in hereditary cerebral hemorrhage, Dutch type. Science 1990; 248: 1124–26. Gretarsdottir S, Sveinbjornsdottir S, Jonsson HH, et al. Localization of a susceptibility gene for common forms of stroke to 5q12. Am J Hum Genet 2002; 70: 593–603. Gretarsdottir S, Thorgeirsson G, Reynisdottir S, et al. The gene encoding phosphodiesterase 4D confers risk of ischemic stroke. Nat Genet 2003; 35: 131–38. Xu RX, Hassell AM, Vanderwall D, et al. Atomic structure of PDE4: insights into phosphodiesterase mechanism and specificity. Science 2000; 288: 1822–25. Buttner T, Hornig CR, Busse O, Dorndorf W. CSF cyclic AMP and CSF adenylate kinase in cerebral ischaemic infarction. J Neurol 1986; 233: 297–303. Iadecola C, Zhang F, Xu S, Casey R, Ross ME. Inducible nitric oxide synthase gene expression in brain following cerebral ischemia. J Cerebral Blood Flow Metab 1995; 15: 378–84. Helgadottir A, Manolescu A, Thorleifsson G, et al, The gene encoding 5-lipoxygenase activating protein confers risk of myocardial infarction and stroke. Nat Genet 2004; 36: 233–39. Spanbroek R, Grabner R, Lotzer K, et al. Expanding expression of the 5-lipoxygenase pathway within the arterial wall during human atherogenesis. Proc Natl Acad Sci USA 2003; 100: 1238–43. Glazier AM, Nadeau JH, Aitman TJ. Finding genes that underlie complex traits. Science 2002; 298: 2345–49.
Pain during prostate biopsy Prostate cancer is a major health issue in the western world, and prostate biopsy guided by transrectal ultrasound (TRUS) is critical for its detection. This diagnostic procedure is invasive and painful, and can often need to be repeated. Up to a quarter of patients find the procedure moderately painful or worse, without analgesia, and nearly a fifth have significant complications, such as voiding difficulties, haematuria, haematospermia and infection.1 Current opinion supports the use of periprostatic infiltration of local anaesthetic as the most effective form of pain relief for TRUS-guided prostate biopsy. The effectiveness of this technique has been established in several studies, including well powered prospective randomised placebo-controlled trials.2,3 1840
Periprostatic local anaesthetic infiltration involves puncture of the rectal wall and injection of local anaesthetic, under ultrasound guidance, into the plane between the prostate and rectum. Our experience of 56 patients, who completed questionnaires after biopsy without analgesia, is that 27% felt that the pain of probe introduction was as bad as or worse than the needle biopsies themselves. Thus, periprostatic infiltration cannot eliminate pain as recently suggested by one small uncontrolled study.4 Surprisingly, there are few published data comparing different probe designs, or even probe size, with pain scores. The infiltration technique is not standardised and several methodological differences affect analgesia. Different local anaesthetic agents and volumes and locations of injection have been studied.3 Most clinicians use short-acting local anaesthetic agents, but when used alone these can lead to rebound pain. Recently, Catherine Lee-Elliott and colleagues5 found that a combination of short-acting and long-acting agents reduced this rebound. In their study, 300 men were randomised to periprostatic infiltration with lidocaine or lidocaine/bupivacaine before biopsy. Mean pain scores, assessed by a visual analogue scale, immediately after biopsy were similar, but at 1 h those patients in the combination group had significantly less pain. Indeed, daily pain over the following week was also significantly lower in the combined group. There was no difference in morbidity between the two groups. Stephen Jones and Craig Zippe6 recently reported a simple adjunct to biopsy after periprostatic infiltration that significantly cut pain in a comparative study of 60 men. Periprostatic infiltration reduces rectal and prostatic pain but is unlikely to affect rectal sensation below the dentate line (figure), due to different sensory innervation. Thus, Jones and Zippe describe a technique for testing rectal sensation with a light touch of a needle before distal (apical) biopsy. Should sensation be intact, the probe is repositioned to avoid piercing the rectum below the dentate line. This test has not been previously described but is used by many urologists. Indeed a rectal probe is widely available that allows the dentate line to be pulled away from the biopsy needle track so that the apex of the prostate can be targeted without increased pain. Although periprostatic local anaesthetic infiltration is regarded as the best method of overcoming the pain of prostate biopsy, several other analgesic techniques have been investigated, which include the rectal administration of topical local anaesthetic, various analgesics (such as oral non-steriodal anti-inflammatory agents and intravenous opioid), an inhaled mixture of 50% nitrous oxide and oxygen,7 and anaesthetic agents. None have proved better than periprostatic local anaesthetic, but topical local anaesthetic is an attractive alternative because it can be administered before the introduction of an ultrasound probe and without needle puncture. Most randomised studies that compare infiltrated local anaesthetic with topical local anaesthetic show that infiltration provides better pain control.2,8 However, Stéphane Mallick and colleagues9 recently reported a randomised study of 328 men, which showed no difference in pain relief between topical and infiltrated local anaesthesia during the biopsy, and much less pain during administration in the topical group. Successful pain control is essential in making TRUSguided prostate biopsy tolerable, and yet even recently few urologists used pain-controlling techniques as standard.10 Pain control is particularly important in the setting of prostate cancer screening, which is widely practised across the world and is currently being investigated in Europe. In this context large numbers of patients are identified as being THE LANCET • Vol 363 • June 5, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
COMMENTARY
Penis Urethra Bladder
Prostate Ultrasound probe
Rectum Level of dentate line
Needle direction through probe guide
Transrectal ultrasound-guided prostate biopsy Diagram shows relation between ultrasound probe, biopsy track, and dentate line during prostatic apex biopsy.
at high risk of cancer on the basis of an increased serum concentration of prostate-specific antigen, and require biopsy. An example of the demand for this procedure is reported by a European prostate-cancer screening trial11 that, with a cut-off for prostate-specific antigen of 3·0 ng/mL, had nearly a fifth of 7943 screened patients undergoing biopsy, with a cancer detection rate of 4·7%. The diagnosis of prostate cancer is being more aggressively pursued, and as screening becomes more widespread and biopsy thresholds with prostate-specific antigen fall, the numbers of biopsies will continue to rise. In addition to primary diagnostic biopsies, there is a corresponding increase in the number of patients with raised prostatespecific antigen but previous sets of negative biopsies that undergo repeat biopsies. In future, the active monitoring of patients already diagnosed with cancer at low risk of progression may also entail programmes of repeat biopsies, possibly every 2 years. Patients will not accept such investigations unless they are tolerable. Arguably, therefore, the effectiveness of prostate cancer screening and active monitoring could be jeopardised by a simple outpatient procedure for which there is currently no universally agreed standard of analgesia. We have no conflict of interest to declare.
*Christopher J Luscombe, Peter W Cooke Department of Urology, Royal Shrewsbury Hospital NHS Trust, Shrewsbury, Shropshire SY3 8XQ, UK (CJL); and Department of Urology, New Cross Hospital, Wolverhampton, West Midlands, UK (PWC) (e-mail: [email protected]) 1
2
3
4
5
6 7
8
Crundwell MC, Cooke PW, Wallace DM. Patients’ tolerance of transrectal ultrasound-guided prostatic biopsy: an audit of 104 cases. BJU Int 1999; 83: 792–95. Lynn NNK, Collins GN, Brown SC, O’Reilly PH. Periprostatic nerve block gives better analgesia for prostatic biopsy. BJU Int 2002; 90: 424–26. Ozden E, Yaman O, Gogus C, Ozgencil E, Soygur T. The optimum doses of and injection locations for periprostatic nerve blockade for transrectal ultrasound guided biopsy of the prostate: a prospective, randomized, placebo controlled study. J Urol 2003; 170: 2319–22. Jones JS, Ulshaker JC, Nelson D, et al. Periprostatic local anaesthesia eliminates pain of office-based transrectal prostate biopsy. Prostate Cancer Prostatic Dis 2003; 6: 53–55. Lee-Elliott CE, Dundas D, Patel U. Randomized trial of lidocaine vs lidocaine/bupivacaine periprostatic injection on longitudinal pain scores after prostate biopsy. J Urol 2004; 171: 247–50. Jones JS, Zippe CD. Rectal sensation test helps avoid pain of apical prostate biopsy. J Urol 2003; 170: 2316–18. Manikandan R, Srirangam SJ, Brown SC, O’Reilly PH, Collins GN. Nitrous oxide vs periprostatic nerve block with 1% lidocaine during transrectal ultrasound guided biopsy of the prostate: a prospective, randomised, controlled trial. J Urol 2003; 170: 1881–83. Adamakis I, Mitropoulos D, Haritroupoulos K, Alamanis C, Stravodimos K, Gianopoulos A. Pain during ultrasonography guided
THE LANCET • Vol 363 • June 5, 2004 • www.thelancet.com
prostate biopsy: a randomized prospective trial comparing periprostatic infiltration with lidocaine with the intrarectal instillation of lidocaineprilocain cream. World J Urol 2003; [epub ahead of print] http://www.springerlink.com/app/home/contribution.asp?wasp=gafwvmv hwq2ghdrknrar&referrer=parent&backto=issue,19,22;journal,1,47;linkin gpublicationresults,id:101581,1 (accessed April 19, 2004). 9 Mallick S, Humbert M, Braud F, Fofana M, Blanchet P. Local anaesthesia before transrectal ultrasound guided prostate biopsy: comparison of 2 methods in a prospective, randomised clinical trial. J Urol 2004; 171: 730–33. 10 Davis M, Sofer M, Kim SS, Soloway MS. The procedure of transrectal ultrasound guided biopsy of the prostate: a survey of patient preparation and biopsy technique. J Urol 2002; 167: 566–70. 11 Schroder FH, Denis LJ, Roobol M. The story of the European randomized study of screening for prostate cancer. BJU Int 2003; 92 (suppl 2): 1–13.
Genetic counselling and prophylactic surgery in women from families with hereditary breast or ovarian cancer The identification1,2 of the two breast cancer genes, BRCA1 and BRCA2, in 1994 and 1995, respectively, and the recognition that mutations in these genes are associated with increased susceptibility to breast and ovarian cancer have led to mutation testing of at-risk families. Many women from families with hereditary breast or ovarian cancer consider bilateral prophylactic mastectomy and/or salpingo-oophorectomy as a strategy to reduce their risk of developing cancer. Decisions about early detection and prophylactic options for high-risk women are particularly difficult because of the uncertain effectiveness of cancer screening and the complexity of the issues to be considered (panel). For high-risk women who have had a mastectomy for breast cancer, decisions about the role of a contralateral mastectomy or indeed bilateral mastectomy after breast conservation are even more complex. Therefore, women considering their risk-management options should have access to genetic counselling, to allow them to make informed decisions. Timothy Rebbeck and colleagues3 recently showed that bilateral prophylactic mastectomy led to a 90% reduction in the risk of breast cancer in carriers of BRCA1 and BRCA2, thus lending further support to the mounting evidence of the procedure’s effectiveness.4 And, in another recent report, Katrina Armstrong and colleagues5 found that bilateral oophorectomy also leads to similar reductions in the risk of ovarian cancer, and, in premenopausal women, the operation decreases the risk of breast cancer by 50%. Because evidence is lacking about the effect of hormone replacement therapy on life expectancy in high-risk women, these investigators did a decision analysis in a simulated cohort, and found that prophylactic oophorectomy increased life expectancy in mutation carriers regardless of whether hormone replacement therapy was used after oophorectomy. However, we need empirical data to confirm these results. We have found6 that women’s intentions to undergo prophylactic mastectomy were correlated with high levels of anxiety about breast cancer, which raises concerns that women might choose surgical intervention without fully anticipating the psychological and medical effects. However, a study7 of actual uptake showed that women who declined the procedure were more prone to anxiety; women who underwent prophylactic mastectomy showed significantly decreased psychological morbidity compared with those who declined the procedure. Reducing the risk of ovarian cancer and worry about cancer are the main decision-making factors in women who have opted for prophylactic oophorectomy.8 A prospective 1841
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Moreover new targets have been identified9,13 for a disease sometimes seen to be languishing in a therapeutic desert with only occasional watering holes. However, our ideas on tackling the genetic basis of cerebrovascular disease clearly need constant revisiting. I have received honoraria for lecturing in industry-sponsored meetings and have received industry funding for attending national and international meetings. I have received research grants from pharmaceutical companies. I have been a paid consultant to the biotech industry.
Pankaj Sharma Department of Cellular and Molecular Neuroscience and Acute Stroke Unit, Hammersmith Hospitals & Imperial College, London W6 8RF, UK (e-mail: [email protected]) 1 2
3
4
5
6
7
8
9
10
11
12
13
14
15
Liao D, Myers R, Hunt S, et al. Familial history of stroke and stroke risk: the Family Heart Study. Stroke 1997; 28: 1908–12. Joutel A, Corpechot C, Ducros A, et al. Notch3 mutations in CADASIL, a hereditary adult-onset condition causing stroke and dementia. Nature 1996; 383: 707–10. Goto Y, Horai S, Matsuoka T, et al. Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS): a correlation study of the clinical features and mitochondrial DNA mutation. Neurology 1992; 42: 545–50. Palsdottir A, Abrahamson M, Thorsteinsson L, et al. Mutation in cystatin C gene causes hereditary brain haemorrhage. Lancet 1988; 2: 603–04. Onda H, Kasuya H, Yoneyama T, et al. Genomewide-linkage and haplotype-association studies map intracranial aneurysm to chromosome 7q11. Am J Hum Genet 2001; 69: 804–19. Laberge-le Couteulx S, Jung HH, Labauge P, M et al. Truncating mutations in CCM1, encoding KRIT1, cause hereditary cavernous angiomas. Nat Genet 1999; 23: 189–93. Levy E, Carman MD, Fernandez-Madrid IJ, et al. Mutation of the Alzheimer’s disease amyloid gene in hereditary cerebral hemorrhage, Dutch type. Science 1990; 248: 1124–26. Gretarsdottir S, Sveinbjornsdottir S, Jonsson HH, et al. Localization of a susceptibility gene for common forms of stroke to 5q12. Am J Hum Genet 2002; 70: 593–603. Gretarsdottir S, Thorgeirsson G, Reynisdottir S, et al. The gene encoding phosphodiesterase 4D confers risk of ischemic stroke. Nat Genet 2003; 35: 131–38. Xu RX, Hassell AM, Vanderwall D, et al. Atomic structure of PDE4: insights into phosphodiesterase mechanism and specificity. Science 2000; 288: 1822–25. Buttner T, Hornig CR, Busse O, Dorndorf W. CSF cyclic AMP and CSF adenylate kinase in cerebral ischaemic infarction. J Neurol 1986; 233: 297–303. Iadecola C, Zhang F, Xu S, Casey R, Ross ME. Inducible nitric oxide synthase gene expression in brain following cerebral ischemia. J Cerebral Blood Flow Metab 1995; 15: 378–84. Helgadottir A, Manolescu A, Thorleifsson G, et al, The gene encoding 5-lipoxygenase activating protein confers risk of myocardial infarction and stroke. Nat Genet 2004; 36: 233–39. Spanbroek R, Grabner R, Lotzer K, et al. Expanding expression of the 5-lipoxygenase pathway within the arterial wall during human atherogenesis. Proc Natl Acad Sci USA 2003; 100: 1238–43. Glazier AM, Nadeau JH, Aitman TJ. Finding genes that underlie complex traits. Science 2002; 298: 2345–49.
Pain during prostate biopsy Prostate cancer is a major health issue in the western world, and prostate biopsy guided by transrectal ultrasound (TRUS) is critical for its detection. This diagnostic procedure is invasive and painful, and can often need to be repeated. Up to a quarter of patients find the procedure moderately painful or worse, without analgesia, and nearly a fifth have significant complications, such as voiding difficulties, haematuria, haematospermia and infection.1 Current opinion supports the use of periprostatic infiltration of local anaesthetic as the most effective form of pain relief for TRUS-guided prostate biopsy. The effectiveness of this technique has been established in several studies, including well powered prospective randomised placebo-controlled trials.2,3 1840
Periprostatic local anaesthetic infiltration involves puncture of the rectal wall and injection of local anaesthetic, under ultrasound guidance, into the plane between the prostate and rectum. Our experience of 56 patients, who completed questionnaires after biopsy without analgesia, is that 27% felt that the pain of probe introduction was as bad as or worse than the needle biopsies themselves. Thus, periprostatic infiltration cannot eliminate pain as recently suggested by one small uncontrolled study.4 Surprisingly, there are few published data comparing different probe designs, or even probe size, with pain scores. The infiltration technique is not standardised and several methodological differences affect analgesia. Different local anaesthetic agents and volumes and locations of injection have been studied.3 Most clinicians use short-acting local anaesthetic agents, but when used alone these can lead to rebound pain. Recently, Catherine Lee-Elliott and colleagues5 found that a combination of short-acting and long-acting agents reduced this rebound. In their study, 300 men were randomised to periprostatic infiltration with lidocaine or lidocaine/bupivacaine before biopsy. Mean pain scores, assessed by a visual analogue scale, immediately after biopsy were similar, but at 1 h those patients in the combination group had significantly less pain. Indeed, daily pain over the following week was also significantly lower in the combined group. There was no difference in morbidity between the two groups. Stephen Jones and Craig Zippe6 recently reported a simple adjunct to biopsy after periprostatic infiltration that significantly cut pain in a comparative study of 60 men. Periprostatic infiltration reduces rectal and prostatic pain but is unlikely to affect rectal sensation below the dentate line (figure), due to different sensory innervation. Thus, Jones and Zippe describe a technique for testing rectal sensation with a light touch of a needle before distal (apical) biopsy. Should sensation be intact, the probe is repositioned to avoid piercing the rectum below the dentate line. This test has not been previously described but is used by many urologists. Indeed a rectal probe is widely available that allows the dentate line to be pulled away from the biopsy needle track so that the apex of the prostate can be targeted without increased pain. Although periprostatic local anaesthetic infiltration is regarded as the best method of overcoming the pain of prostate biopsy, several other analgesic techniques have been investigated, which include the rectal administration of topical local anaesthetic, various analgesics (such as oral non-steriodal anti-inflammatory agents and intravenous opioid), an inhaled mixture of 50% nitrous oxide and oxygen,7 and anaesthetic agents. None have proved better than periprostatic local anaesthetic, but topical local anaesthetic is an attractive alternative because it can be administered before the introduction of an ultrasound probe and without needle puncture. Most randomised studies that compare infiltrated local anaesthetic with topical local anaesthetic show that infiltration provides better pain control.2,8 However, Stéphane Mallick and colleagues9 recently reported a randomised study of 328 men, which showed no difference in pain relief between topical and infiltrated local anaesthesia during the biopsy, and much less pain during administration in the topical group. Successful pain control is essential in making TRUSguided prostate biopsy tolerable, and yet even recently few urologists used pain-controlling techniques as standard.10 Pain control is particularly important in the setting of prostate cancer screening, which is widely practised across the world and is currently being investigated in Europe. In this context large numbers of patients are identified as being THE LANCET • Vol 363 • June 5, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
COMMENTARY
Penis Urethra Bladder
Prostate Ultrasound probe
Rectum Level of dentate line
Needle direction through probe guide
Transrectal ultrasound-guided prostate biopsy Diagram shows relation between ultrasound probe, biopsy track, and dentate line during prostatic apex biopsy.
at high risk of cancer on the basis of an increased serum concentration of prostate-specific antigen, and require biopsy. An example of the demand for this procedure is reported by a European prostate-cancer screening trial11 that, with a cut-off for prostate-specific antigen of 3·0 ng/mL, had nearly a fifth of 7943 screened patients undergoing biopsy, with a cancer detection rate of 4·7%. The diagnosis of prostate cancer is being more aggressively pursued, and as screening becomes more widespread and biopsy thresholds with prostate-specific antigen fall, the numbers of biopsies will continue to rise. In addition to primary diagnostic biopsies, there is a corresponding increase in the number of patients with raised prostatespecific antigen but previous sets of negative biopsies that undergo repeat biopsies. In future, the active monitoring of patients already diagnosed with cancer at low risk of progression may also entail programmes of repeat biopsies, possibly every 2 years. Patients will not accept such investigations unless they are tolerable. Arguably, therefore, the effectiveness of prostate cancer screening and active monitoring could be jeopardised by a simple outpatient procedure for which there is currently no universally agreed standard of analgesia. We have no conflict of interest to declare.
*Christopher J Luscombe, Peter W Cooke Department of Urology, Royal Shrewsbury Hospital NHS Trust, Shrewsbury, Shropshire SY3 8XQ, UK (CJL); and Department of Urology, New Cross Hospital, Wolverhampton, West Midlands, UK (PWC) (e-mail: [email protected]) 1
2
3
4
5
6 7
8
Crundwell MC, Cooke PW, Wallace DM. Patients’ tolerance of transrectal ultrasound-guided prostatic biopsy: an audit of 104 cases. BJU Int 1999; 83: 792–95. Lynn NNK, Collins GN, Brown SC, O’Reilly PH. Periprostatic nerve block gives better analgesia for prostatic biopsy. BJU Int 2002; 90: 424–26. Ozden E, Yaman O, Gogus C, Ozgencil E, Soygur T. The optimum doses of and injection locations for periprostatic nerve blockade for transrectal ultrasound guided biopsy of the prostate: a prospective, randomized, placebo controlled study. J Urol 2003; 170: 2319–22. Jones JS, Ulshaker JC, Nelson D, et al. Periprostatic local anaesthesia eliminates pain of office-based transrectal prostate biopsy. Prostate Cancer Prostatic Dis 2003; 6: 53–55. Lee-Elliott CE, Dundas D, Patel U. Randomized trial of lidocaine vs lidocaine/bupivacaine periprostatic injection on longitudinal pain scores after prostate biopsy. J Urol 2004; 171: 247–50. Jones JS, Zippe CD. Rectal sensation test helps avoid pain of apical prostate biopsy. J Urol 2003; 170: 2316–18. Manikandan R, Srirangam SJ, Brown SC, O’Reilly PH, Collins GN. Nitrous oxide vs periprostatic nerve block with 1% lidocaine during transrectal ultrasound guided biopsy of the prostate: a prospective, randomised, controlled trial. J Urol 2003; 170: 1881–83. Adamakis I, Mitropoulos D, Haritroupoulos K, Alamanis C, Stravodimos K, Gianopoulos A. Pain during ultrasonography guided
THE LANCET • Vol 363 • June 5, 2004 • www.thelancet.com
prostate biopsy: a randomized prospective trial comparing periprostatic infiltration with lidocaine with the intrarectal instillation of lidocaineprilocain cream. World J Urol 2003; [epub ahead of print] http://www.springerlink.com/app/home/contribution.asp?wasp=gafwvmv hwq2ghdrknrar&referrer=parent&backto=issue,19,22;journal,1,47;linkin gpublicationresults,id:101581,1 (accessed April 19, 2004). 9 Mallick S, Humbert M, Braud F, Fofana M, Blanchet P. Local anaesthesia before transrectal ultrasound guided prostate biopsy: comparison of 2 methods in a prospective, randomised clinical trial. J Urol 2004; 171: 730–33. 10 Davis M, Sofer M, Kim SS, Soloway MS. The procedure of transrectal ultrasound guided biopsy of the prostate: a survey of patient preparation and biopsy technique. J Urol 2002; 167: 566–70. 11 Schroder FH, Denis LJ, Roobol M. The story of the European randomized study of screening for prostate cancer. BJU Int 2003; 92 (suppl 2): 1–13.
Genetic counselling and prophylactic surgery in women from families with hereditary breast or ovarian cancer The identification1,2 of the two breast cancer genes, BRCA1 and BRCA2, in 1994 and 1995, respectively, and the recognition that mutations in these genes are associated with increased susceptibility to breast and ovarian cancer have led to mutation testing of at-risk families. Many women from families with hereditary breast or ovarian cancer consider bilateral prophylactic mastectomy and/or salpingo-oophorectomy as a strategy to reduce their risk of developing cancer. Decisions about early detection and prophylactic options for high-risk women are particularly difficult because of the uncertain effectiveness of cancer screening and the complexity of the issues to be considered (panel). For high-risk women who have had a mastectomy for breast cancer, decisions about the role of a contralateral mastectomy or indeed bilateral mastectomy after breast conservation are even more complex. Therefore, women considering their risk-management options should have access to genetic counselling, to allow them to make informed decisions. Timothy Rebbeck and colleagues3 recently showed that bilateral prophylactic mastectomy led to a 90% reduction in the risk of breast cancer in carriers of BRCA1 and BRCA2, thus lending further support to the mounting evidence of the procedure’s effectiveness.4 And, in another recent report, Katrina Armstrong and colleagues5 found that bilateral oophorectomy also leads to similar reductions in the risk of ovarian cancer, and, in premenopausal women, the operation decreases the risk of breast cancer by 50%. Because evidence is lacking about the effect of hormone replacement therapy on life expectancy in high-risk women, these investigators did a decision analysis in a simulated cohort, and found that prophylactic oophorectomy increased life expectancy in mutation carriers regardless of whether hormone replacement therapy was used after oophorectomy. However, we need empirical data to confirm these results. We have found6 that women’s intentions to undergo prophylactic mastectomy were correlated with high levels of anxiety about breast cancer, which raises concerns that women might choose surgical intervention without fully anticipating the psychological and medical effects. However, a study7 of actual uptake showed that women who declined the procedure were more prone to anxiety; women who underwent prophylactic mastectomy showed significantly decreased psychological morbidity compared with those who declined the procedure. Reducing the risk of ovarian cancer and worry about cancer are the main decision-making factors in women who have opted for prophylactic oophorectomy.8 A prospective 1841
For personal use. Only reproduce with permission from The Lancet Publishing Group.