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Choosing Wisely

I recently have become aware of an organization with a campaign called “Choosing Wisely” whose goal is to improve quality and reduce waste by getting physicians and patients talking about medical tests and procedures which may be unnecessary and possibly harmful.

So far, more than 60 national medical societies have joined the initiative (www.choosingwisely.org) to identify and create lists of the top five tests and procedures that they say are over-used or inappropriate.

The more than 300 Choosing Wisely recommendations can be overwhelming, so a provider needs to start with guidelines to relate to conditions they see most often in their practice.

This informational provided by Dr. Goldberg, a Dallas / Fort Worth Urologist, addresses four of the five American Urological Association procedures that they say are over-used or inappropriate. (www.choosingwisely.org/doctor-patient-lists/american-urological-association/)

1. A routine bone scan is unnecessary in men with low-risk prostate cancer. Low-risk patients are unlikely to have disease identified by bone scan. Accordingly, bone scans are generally unnecessary in patients with newly diagnosed prostate cancer who have a PSA less than 20.0 ng / ml and a Gleason score 6 or less unless the patient's history or clinical examination suggests bone involvement. I personally extend the Gleason score to 7 (3 + 4). In men with Gleason 7 (4 + 3) a bone scan would depend on the number of cores that were positive and percent of grade of Gleason 4 present. Additionally, in elderly patients who have PSAs over 10, I frequently will do a bone scan prior to considering a prostate biopsy since a negative bone scan would indicate no evidence of metastatic disease and no indication to treat these elderly. One additional note, the PET bone scan F-19 has shown to be more sensitive than a routine bone scan, however, it is currently only approved and utilized for the Medicare patients.

2. Don't prescribe testosterone to men with erectile dysfunction who have normal testosterone levels. While testosterone treatment is shown to increase sexual interest, there appears to be no significant influence on erectile function at least in men with normal testosterone levels. As you are aware, there is a significant amount of controversy in question regarding testosterone replacement therapy and its potential to increase cardiovascular risk, morbidity, and even death. (Please refer to prior Update "Testosterone and Heart Disease") Numerous articles have been published which countered this belief. The FDA is scheduling a Summit Meeting in mid-September and hopefully, their findings will be released a month or two later. I plan on keeping you informed with an update once that report is issued.

3. Don't order creatinine or upper-tract imaging for patients with benign prostatic hyperplasia (BPH). I certainly agree that simple BPH patients do not need upper-tract imaging but I do not believe this holds for men with significant residual urine (greater than 250). Increasing residual urine can be associated with infection and impairment of kidney function. Certainly, a baseline creatinine and even an ultrasound are not unreasonable.

4. Don't treat an elevated PSA with antibiotics for patients not experiencing other symptoms. It had previously been suggested that a course of antibiotics might lead to a decrease in an initially raised PSA and thus reduce the need for prostate biopsy; however, there is lack of clinical studies to show that antibiotics actually decrease PSA levels. Additionally, there has been a marked increase in the incidence of post-prostatic biopsy bacteremia and sepsis (1-2%). This is due primarily to E. coli bacteria resistant to Cipro or Levaquin. Placing a man on antibiotics for an elevated PSA who is asymptomatic, and his PSA doesn't drop, is then at risk for resistant E. coli which could lead to bacteremia or sepsis. In fact, we have recently contracted with the University of Irvine Out-Patient Testing to perform stool cultures for E. coli resistant bacteria prior to doing a prostate biopsy in men who either have had antibiotics in the past six months or are at significant risk for complications.

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