General practitioners' perceptions of medicolegal risk. Using case scenarios to assess the potential impact of prostate cancer screening guidelines

“It was an important part of my treatment”: a qualitative study of Norwegian breast Cancer patients’ experiences with mainstreamed genetic testing

Background

In South-Eastern Norway, genetic testing for BRCA1 and BRCA2 is offered to breast cancer patients by their treating surgeon or oncologist. Genetic counselling from a geneticist or a genetic counsellor is offered only to those who test positive for a pathogenic variant or have a family history of cancer. This practice is termed “mainstreamed genetic testing”. The aim of this study was to learn about patients’ experience of this healthcare service.

Methods

Qualitative in-depth interviews were conducted with 22 breast cancer patients who had been diagnosed during the first half of 2016 or 2017 at one regional and one university hospital and who had been offered testing by their treating physician. A six-phase thematic approach was used to analyse the data.

Results

The participants had varied experiences of how and when testing was offered. Three main themes emerged from the analysis: 1. informational and communicational needs and challenges during a chaotic time, 2. the value of genetic testing and 3. the importance of standardised routines for mainstreamed genetic testing.

Conclusions

Despite the shock of their diagnosis and the varying experiences they had in respect of how and when testing was offered, all of the participants emphasised that genetic testing had been an important part of their diagnosis and treatment. Our results indicate that there is a need for continuous collaboration between geneticists, surgeons, oncologists and laboratory specialists in order to establish simple and robust routines so as to ensure that all eligible breast cancer patients are offered testing at a point when the test result can have an impact on treatment.

Study on the pathophysiological mechanism responsible for lower urinary tract symptoms associated with prostate cancer using an animal model

OBJECTIVES

To investigate the pathophysiological mechanism leading to lower urinary tract symptoms in prostate cancer (PCa) by using an animal model.

METHODS

An orthotopic PCa model in mice was established by injection of human DU145 cells into the prostate gland lateral lobe of NOD.CB17-Prkdc^scid /NcrCrlBltw (NOD-SCID) mice. Cancer growth was quantified by a luciferase-based in vivo imaging system (IVIS) serially every 7 days. Comparisons were made for urodynamic parameters, bladder histology, and biological markers until the sixth week. Bladder wall structural changes were assessed by the bladder wall thickness and degree of fibrosis. Biomarker expressions in bladder tissue including muscarinic acetylcholine receptor 2 (M₂ ), transient receptor potential cation channel subfamily V member 4 (TRPV4), BCL2-associated X protein (Bax), and caspase3 were evaluated by immunohistochemical staining and immunofluorescence confocal laser scanning microscopy.

RESULTS

DU145 cell growth in the prostate was successfully monitored by a luciferase-based IVIS. after orthotopic injection. Using our injection technique, no anatomical obstruction of the bladder outlet and urethra was noted up to 6 weeks after injection. The presence of PCa induced changes in urinary bladder histology, biomarkers, and urodynamic parameters. Cystometry showed features of detrusor overactivity with increased voiding frequency and high-amplitude voiding contractions from the fourth week onward. Histological analyses 4 weeks after DU145 injection demonstrated detrusor thickening and bladder wall fibrosis. Immunohistochemistry showed increased expressions of bladder M₂ , TRPV4, Bax, and caspase3 in the PCa mice as early as in the first or second week.

CONCLUSIONS

PCa can induce bladder microenvironment changes involving neural receptors and biological mediators leading to histological and functional alterations even in the absence of overt anatomical obstruction.

Can shared decision-making reduce medical malpractice litigation? A systematic review

Background

To explore the likely influence and impact of shared decision-making on medical malpractice litigation and patients’ intentions to initiate litigation.

Methods

We included all observational, interventional and qualitative studies published in all languages, which assessed the effect or likely influence of shared decision-making or shared decision-making interventions on medical malpractice litigation or on patients’ intentions to litigate. The following databases were searched from inception until January 2014: CINAHL, Cochrane Register of Controlled Trials, Cochrane Database of Systematic Reviews, EMBASE, HMIC, Lexis library, MEDLINE, NHS Economic Evaluation Database, Open SIGLE, PsycINFO and Web of Knowledge. We also hand searched reference lists of included studies and contacted experts in the field. Downs & Black quality assessment checklist, the Critical Appraisal Skill Programme qualitative tool, and the Critical Appraisal Guidelines for single case study research were used to assess the quality of included studies.

Results

6562 records were screened and 19 articles were retrieved for full-text review. Five studies wee included in the review. Due to the number and heterogeneity of included studies, we conducted a narrative synthesis adapted from the ESRC guidance for narrative synthesis. Four themes emerged. The analysis confirms the absence of empirical data necessary to determine whether or not shared decision-making promoted in the clinical encounter can reduce litigation. Three out of five included studies provide retrospective and simulated data suggesting that ignoring or failing to diagnose patient preferences, particularly when no effort has been made to inform and support understanding of possible harms and benefits, puts clinicians at a higher risk of litigation. Simulated scenarios suggest that documenting the use of decision support interventions in patients’ notes could offer some level of medico-legal protection. Our analysis also indicated that a sizeable proportion of clinicians prefer ordering more tests and procedures, irrespective of patient informed preferences, as protection against litigation.

Conclusions

Given the lack of empirical data, there is insufficient evidence to determine whether or not shared decision-making and the use of decision support interventions can reduce medical malpractice litigation. Further investigation is required.

Trial registration

This review was registered on PROSPERO. Registration number: CRD42012002367.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0823-2) contains supplementary material, which is available to authorized users.

Doctors' approaches to PSA testing and overdiagnosis in primary healthcare: a qualitative study

OBJECTIVES

(1) To explain general practitioners' (GPs') approaches to prostate-specific antigen (PSA) testing and overdiagnosis; (2) to explain how GPs reason about their PSA testing routines and (3) to explain how these routines influence GPs' personal experience as clinicians.

SETTING

Primary care practices in Australia including men's health clinics and rural practices with variable access to urology services.

PARTICIPANTS

32 urban and rural GPs within Australia. We included GPs of varying ages, gender (11 female), clinical experience and patient populations. All GPs interested in participating in the study were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data were analysed using grounded theory methods to determine how and why GPs provide (or do not provide) PSA testing to their asymptomatic male patients.

RESULTS

We observed patterned variation in GP practice, and identified four heuristics to describe GP preference for, and approaches to, PSA testing and overdiagnosis: (1) GPs who prioritised avoiding underdiagnosis, (2) GPs who weighed underdiagnosis and overdiagnosis case by case, (3) GPs who prioritised avoiding overdiagnosis and (4) GPs who did not engage with overdiagnosis at all. The heuristics guided GPs' Routine Practice (usual testing, communication and responses to patient request). The heuristics also reflected GPs' different Practice Rationales (drawing on experience, medicolegal obligations, guidelines and evidence) and produced different Practice Outcomes (GPs' experiences of the consequences of their PSA testing decisions). Some of these heuristics were more responsive to patient preferences than others.

CONCLUSIONS

Variation in GPs' PSA testing practices is strongly related to their approach to overdiagnosis and underdiagnosis of prostate cancer. Men receive very different care depending on their GP's reasoning and practice preferences. Future policy to address overdiagnosis will be more likely to succeed if it responds to these patterned variations.

Defensive medicine in Israel - a nationwide survey

BACKGROUND

Defensive medicine is the practice of diagnostic or therapeutic measures conducted primarily as a safeguard against possible malpractice liability. We studied the extent, reasons, and characteristics of defensive medicine in the Israeli health care system.

METHODS AND FINDINGS

Cross-sectional study performed in the Israeli health care system between April and July 2008 in a sample (7%) of board certified physicians from eight medical disciplines (internal medicine, pediatrics, general surgery, family medicine, obstetrics and gynecology, orthopedic surgery, cardiology, and neurosurgery). A total of 889 physicians (7% of all Israeli board certified specialists) completed the survey. The majority [60%, (95%CI 0.57-0.63)] reported practicing defensive medicine; 40% (95%CI 0.37-0.43) consider every patient as a potential threat for a medical lawsuit; 25% (95%CI 0.22-0.28) have previously been sued at least once during their career. Independent predictors for practicing defensive medicine were surgical specialty [OR=1.6 (95%CI 1.2-2.2), p=0.0004], not performing a fellowship abroad [OR=1.5 (95%CI 1.1-2), p=0.027], and previous exposure to lawsuits [OR=2.4 (95%CI 1.7-3.4), p<0.0001]. Independent predictors for the risk of being sued during a physician's career were male gender [OR=1.6 (95%CI 1.1-2.2), p=0.012] and surgery specialty [OR=3.2 (95%CI 2.4-4.3), p<0.0001] (general surgery, obstetrics and gynecology, orthopedic surgery, and neurosurgery).

CONCLUSIONS

Defensive medicine is very prevalent in daily physician practice in all medical disciplines. It exposes patients to complications due to unnecessary tests and procedures, affects quality of care and costs, and undermines doctor-patient relationships. Further studies are needed to understand how to minimize defensive medicine resulting from an increased malpractice liability market.

The absence of voiding symptoms in men with a prostate-specific antigen (PSA) concentration of ≥3.0 ng/mL is an independent risk factor for prostate cancer: results from the Gothenburg Randomized Screening Trial

What's known on the subject? and What does the study add? There are only a few studies and no consensus concerning the relationship between LUTS and prostate cancer. This paper focuses on 2353 men with an elevated PSA level within the Gothenburg Randomized Screening Trial who underwent biopsy and answered questions regarding LUTS. The main conclusion was that the absence of voiding symptoms is an independent risk factor for prostate cancer detection.

OBJECTIVE

To investigate whether men with obstructive voiding symptoms are at increased risk for being diagnosed with prostate cancer within the Gothenburg randomized population-based prostate cancer screening trial.

SUBJECTS AND METHODS

In 1995, 20 000 men born between 1930 and 1944 were randomly selected from the population register and randomized to either a screening group (10 000), invited for total prostate-specific antigen (tPSA) testing every second year until they reached an upper age-limit pending between 67 and 71 years, or to a control group not invited (10 000). Men with a PSA concentration of ≥3.0 ng/mL were offered further examination with prostate biopsies. Immediately before the physician's examination a self-administered, study-specific questionnaire was completed including one question concerning obstructive voiding symptoms. Multivariate logistic regression modelling was used to estimate odds ratios (ORs) for associations of age, tPSA, free/total PSA (f/tPSA) ratio, prostate volume and the presence of voiding symptoms in prostate cancer risk. A P < 0.05 was considered statistically significant.

RESULTS

Between 1995 and 2010 there were 2590 men who had an elevated PSA concentration (≥3.0 ng/mL) at least once during the study. Of these, 2353 men (91%) accepted further clinical examination with transrectal ultrasonography (TRUS) and prostate biopsies. In all, 633/2353 men had prostate cancer (27%) on biopsy and 1720/2353 men (73%) had a benign pathology. Men with prostate cancer reported a lower frequency of voiding symptoms (24% vs 31%, P < 0.001), independent of age and locally advanced tumours (T2b-T4). In the multivariate logistic regression model increasing age and tPSA were positively associated with prostate cancer while prostate volume, f/tPSA ratio and the presence of voiding symptoms were all inversely associated with the risk of detecting prostate cancer in a screening setting. This inverse association of voiding symptoms and prostate cancer detection was restricted to men with large prostates (>37.8 mL); 15% in men with voiding symptoms vs 22% in asymptomatic men (P < 0.001).

CONCLUSION

The presence of voiding symptoms should not be a decision tool for deciding which men with an elevated PSA concentration should be offered biopsies of the prostate.

Legal concerns trigger prostate-specific antigen testing

BACKGROUND

In the United States, lawsuits against physicians have had an impact on their behaviour, resulting in overdiagnosis and other forms of 'defensive medicine'. Does a similar situation exist in Switzerland? Using prostate-specific antigen (PSA) screening as an example, we surveyed Swiss physicians and assessed the extent to which liability fears influenced their recommendation for testing.

METHODS

At a continuing medical education conference we distributed a pilot-tested questionnaire to 552 participants. Two hundred and fifty of them (45%) completed the questionnaire.

RESULTS

Of the participants, 158 (68%) were general practitioners and 73 (32%) specialists in internal medicine. Seventy-five per cent of both groups recommend regular PSA screening to men older than age 50. Yet only 56% of the general physicians and 53% of the internists believe that PSA measurement is an effective screening method. A substantial proportion of the physicians - 41% of general practitioners and 43% of internists - reported that they sometimes or often recommend this test for legal reasons.

CONCLUSIONS

Defensive medicine is not a phenomenon particular to the USA, but is also observable in Switzerland. This result is surprising, given that in Switzerland and other European countries, a physician who does not recommend a test or treatment whose effectiveness is controversial need not fear litigation.

Factors prompting PSA-testing of asymptomatic men in a country with no guidelines: a national survey of general practitioners

Background

Increased use of prostate specific antigen (PSA) has been associated with increased prostate cancer incidence. Ireland is estimated to have one of the highest prostate cancer incidences in Europe and has no national guidelines for prostate cancer screening. GPs have a pivotal role in influencing PSA testing, therefore, our aim was to describe GP testing practices and to identify factors influencing these.

Methods

A postal survey, including questions on clinical practice and experience, knowledge and demographics was distributed to all GPs (n = 3,683). The main outcomes were (i) PSA testing asymptomatic men and (ii) "inappropriate" PSA testing, defined as testing asymptomatic men aged < 50 or > 75 years. Factors associated with these outcomes were identified using logistic regression.

Results

1,625 GPs responded (response rate corrected for eligibility = 53%). Most respondents (79%) would PSA test asymptomatic men. Of these, 34% and 51% would test asymptomatic men < 50 and > 75 years, respectively. In multivariate analyses, GPs were more likely to test asymptomatic men if they were ≥ 50 years, in practice ≥ 10 years, female or less knowledgeable about PSA efficacy. Male GPs who would have a PSA test themselves were > 8-times more likely to PSA test asymptomatic men than GPs who would not have a test. GPs who had an asymptomatic patient diagnosed with prostate cancer following PSA testing, were > 3-times more likely to test asymptomatic men. Practice-related factors positively associated with testing included: running 'well man' clinics, performing occupational health checks and performing other tests routinely with PSA. Factors positively associated with 'inappropriate' testing included; being male and willing to have a PSA test, having worked/trained in the UK and supporting annual PSA testing. 91% of respondents supported the development of national PSA testing guidelines.

Conclusion

Our findings suggest that widespread PSA testing of asymptomatic men in primary care is primarily due to a combination of clinical experience, poor knowledge and the support of doctors for PSA testing, as evidenced by the willingness of male doctors to have a PSA test. There is an urgent need for education and support for GPs concerning prostate cancer screening, starting with the implementation of national guidelines.

Prostate-specific antigen testing: uncovering primary care influences

OBJECTIVES

To examine influences on the behaviour of General Practitioner (GP) in relation to prostate-specific antigen (PSA) testing.

SUBJECTS AND METHODS

In Northern Ireland in 2003-2004, all GPs (1067) were invited to complete a self-administered postal questionnaire survey that was then matched with a regional PSA-testing database. The main outcome measures were individual GP responses for demographic, practice and training characteristics, PSA testing behaviour and perceived influences, matched against GP-initiated first PSA tests performed in 2003 and 2004 (22 207 tests).

RESULTS

In all, 704 GPs (66%) responded and 49% of these reported awareness of the national guidelines, which was highest among those attending postgraduate meetings. PSA tests were more likely to be ordered by full-time male GPs who had attended a local postgraduate urology meeting; ran a 'well-man' clinic; tested men with unrelated complaints; and were not in a training practice. Testing levels were highest among GPs who had been practising for 21-30 years and those in rural practices. Awareness of national guidelines or having had a postgraduate post in urology did not affect testing behaviour. After adjusting for gender, working hours, duration in practice and urban/rural setting, independent influences increasing testing behaviour were: testing men with a positive family history or unrelated complaints; testing any man who requests it; and previous experience of prostate cancer being detected in an asymptomatic patient by PSA testing. Working in an accredited training practice was associated with lower testing levels.

CONCLUSION

There are complex influences on the PSA testing behaviour of GPs; addressing these influences could contribute to the rationalization of testing. A low awareness of national guidelines indicates a need for new strategies to disseminate and implement guidelines. The influence of local educational meetings on PSA testing is an unharnessed force.

Being screened for prostate cancer: a simple blood test or a commitment to treatment?

The virtues of screening men for prostate cancer continue to be debated in political and public health, as well as clinical forums. Science has been unable to accurately predict screening benefits, yet many men are required to make informed decisions about prostate cancer screening. Clinicians' screening practices have been reported, but little research attention has been given to patients' experiences. The purpose of this study was to describe patients' perspectives of being screened and subsequently diagnosed with prostate cancer. Thirty-five Anglo-Australian men were interviewed, and the data were analyzed using ethnographic content analysis. The findings indicated that most participants experienced screening as a continuum of 3 tests, rather than the simple prostate-specific antigen blood test they had often anticipated. Commitment to a definitive diagnosis when abnormality was detected through screening and uptake of active treatment(s) when prostate cancer was confirmed were strongly represented in this study. The findings offer insight to the complex and often rapid sequence of events that can accompany prostate cancer screening. This has implications for the information that needs to be discussed with men before, rather than after prostate cancer screening has commenced.

Does 'peer coaching' increase GP capacity to promote informed decision making about PSA screening? A cluster randomised trial

BACKGROUND

Very little effort has been directed to enable GPs to better informed decisions about PSA screening among their male patients.

OBJECTIVES

To evaluate an innovative programme designed to enhance GPs' capacity to promote informed decision making by male patients about PSA screening.

METHODS

The study design was a cluster randomised controlled trial set in New South Wales, Australia's most populous state. 277 GPs were recruited through a major pathology laboratory. The interventions were three telephone-administered 'peer coaching' sessions integrated with educational resources for GPs and patients and the main outcome measures were: GP knowledge; perceptions of patient involvement in informed decision making; GPs' own decisional conflict; and perceptions of medicolegal risk.

RESULTS

Compared with GPs allocated to the control group, GPs allocated to our intervention gained significantly greater knowledge about PSA screening and related information [Mean 6.1 out of 7; 95% confidence interval (CI) = 5.9-6.3 versus 4.8; 95% CI = 4.6-5.0; P < 0.001]. They were less likely to agree that patients should remain passive when making decisions about PSA screening [Odds ratio (OR) = 0.11; 95% CI = 0.04-0.31; P < 0.001]. They perceived less medicolegal risk when not acceding to an 'uninformed' patient request for a PSA test (OR = 0.31; 95% CI 0.19-0.51). They also demonstrated lower levels of personal decisional conflict about the PSA screening (Mean 25.4; 95% CI 24.5-26.3 versus 27.8; 95% CI 26.6-29.0; P = 0.0002).

CONCLUSION

A 'peer coaching' programme, supplemented by education materials, holds promise as a strategy to equip GPs to facilitate informed decision making amongst their patients.

GP and patient predictors of PSA screening in Australian general practice

OBJECTIVE

We determined GP and patient variables associated first with men's prior uptake of prostate-specific antigen (PSA) screening and, subsequently, its initiation during an 'index consultation' in Australian general practice.

METHODS

From the practices of 60 GPs, we recruited a sample of 423 male patients aged 40-70 years. In a waiting room questionnaire completed before their 'index consultation' (retrospective component), men reported their previous PSA screening status. We obtained demographic and clinical data, including the presence of lower urinary tract symptoms (LUTS). Men also were mailed a questionnaire 2 days after their 'index consultation' to ascertain whether the GP had discussed PSA screening (prospective component) for prostate cancer and other behaviours. GPs themselves completed questionnaires eliciting demographic and practice characteristics as well as their propensity to screen and understanding of the evidence about PSA testing. GP and patient study variables were modelled simultaneously in analyses.

RESULTS

Of those 348 men consulting with their regular GP, 80 (23.0%) reported previously having had a PSA screening test. Men were significantly and independently more likely ever to have had PSA screening if their regular GP reported a propensity to initiate screening [adjusted odds ratio (AOR) = 2.27, 95% confidence interval (CI) 1.23-4.20; P = 0.009]. GP age also was independently associated with men's PSA screening status [chi-squared (3) P < 0.0001] as was men's age and severity of LUTS (AOR = 2.38, 95% CI 1.58-3.57, P < 0.0001 and AOR = 1.79, 95% CI 1.00-3.19, P = 0.004, respectively). Current smokers were less likely ever to have had a PSA screening test (AOR = 0.34, 95% CI 0.16-0.69; P = 0.003). Discussion of PSA screening in their 'index consultation' was recalled independently more often by older men (AOR = 1.46, 95% CI 1.00-2.13; P = 0.04), those with moderate/severe LUTS (AOR = 1.94, 1.07-3.49; P = 0.04), those whose GP had performed or discussed a cholesterol test (AOR = 2.26, 95% CI 1.03-4.92; P = 0.04) and those whose GP had postgraduate training in family medicine (AOR = 3.13, 95% CI 1.23-8.00; P = 0.02).

CONCLUSION

In the absence as yet of compelling evidence that PSA screening will prolong life or enhance its quality, our findings identify GP and patient factors that could be targeted to modify PSA screening.

Clinicians' attitudes to clinical practice guidelines: a systematic review

OBJECTIVE

To systematically review surveys of clinicians' attitudes to clinical practice guidelines.

DATA SOURCES

MEDLINE, HealthStar, Embase and CINAHL were searched electronically for English-only surveys published from 1990 to 2000.

STUDY SELECTION

We included surveys with responses to one or more of seven propositions (see below). Studies were excluded if they had fewer than 100 respondents or if the response rate was less than 60%.

RESULTS

Thirty studies included responses to one or more of the seven items, giving a total of 11 611 responses. The response rate for the included studies was 72% (95% confidence interval [CI], 69%-75%). Clinicians agreed that guidelines were helpful sources of advice (weighted mean, 75%; 66%-83%), good educational tools (71%; 63%-79%) and intended to improve quality (70%; 60%-80%). However, clinicians also considered guidelines impractical and too rigid to apply to individual patients (30%; 23%-36%), that they reduced physician autonomy and oversimplified medicine (34%; 22%-47%), would increase litigation (41%; 32%-49%) and were intended to cut healthcare costs (52.8%; 39%-66%).

CONCLUSIONS

Surveys of healthcare providers consistently report high satisfaction with clinical practice guidelines and a belief that they will improve quality, but there are concerns about the practicality of guidelines, their role in cost-cutting and their potential for increasing litigation.

Practice trends in the management of prostate disease by family practice physicians and general internists: an internet-based survey

OBJECTIVES

To assess, using an Internet-based survey, the practice patterns of primary care physicians in the management of prostate disease and to assess the differences between family physicians and general internists. Prostate cancer and benign prostatic hyperplasia are common in the elderly population. The optimal management of these diseases is debated.

METHODS

An 18-item survey was designed and administered on an Internet website. Members of the Society of General Internal Medicine and members of the Illinois, North Carolina, and New York chapters of the Academy of Family Physicians were surveyed.

RESULTS

A total of 354 responses were obtained from 381 primary care physicians who viewed the survey web page. For patients 50 years old and older, 75% of physicians (87% of family physicians and 69% of general internists; P <0.001) recommended annual prostate cancer screening with digital rectal examination and 49% (67% of family physicians and 40% of general internists; P <0.001) recommended annual prostate cancer screening with prostate-specific antigen measurement. For patients diagnosed with prostate cancer, 76% of the primary care physicians estimated that less than one half of their patients are seen by a radiation oncologist. For the treatment and/or prevention of prostate cancer, 62% of physicians surveyed (76% of family physicians and 55% of general internists; P <0.001) believe there is a potential role for alternative herbal and nutritional therapies.

CONCLUSIONS

Compared with general internists, family physicians are more likely to screen for prostate cancer and are more likely to believe there is a role for alternative therapies for prostate cancer.

Attitudes to evidence-based practice in urology: results of a survey

BACKGROUND

The advantages of promoting evidence-based care through implementation of clinical guidelines are well established. Clinical practice guidelines have been developed for lower urinary tract symptoms (LUTS) and prostate cancer screening. Aspects of the delivery of care by urologists or specialist registrars relevant to the guidelines were assessed.

METHODS

A questionnaire was distributed at the 1999 meeting of the Urological Society of Australasia, which was attended by 187 Australasian and 33 foreign delegates. Questions addressed access to resources for evidence-based medicine; perceived need; preferred sources of information; and then presented four clinical scenarios. These were: (i) treatment recommendations in early stage prostate cancer; (ii) the same scenario if the respondent was the patient; (iii) treatment recommendations after radical prostatectomy when there was a positive resection margin; and (iv) clinical investigations for mild to moderate LUTS.

RESULTS

Of 220 possible responses, 132 were received, a response rate of 60%. Urologists overwhelmingly (100%) endorsed the need for access to evidence-based reviews, although 28% claimed such access was non-existent to poor. Clinical guidelines were the preferred source of evidence-based information. For early stage prostate cancer in a 55-year-old man, radical prostatectomy was recommended by 93.2% of respondents, but this dropped to 83% when the respondent was the patient (P < 0.05), and a wider range of treatments was recommended. Pelvic radiotherapy and hormone therapy were equally recommended for biochemical progression following radical prostatectomy where there was a positive surgical margin. Investigations for LUTS included serum prostate-specific antigen (PSA) testing (78.0%) and voided flow studies (77.3%).

CONCLUSIONS

Urologists express a need for evidence-based practice resources, in particular clinical guidelines. Nevertheless their clinical approach is not necessarily consistent with existing guidelines, particularly for LUTS. An alteration in the recommendation when the respondent is the patient of interest and endorses the recommendation that patients with prostate cancer should be involved in treatment decisions.