The Ever-evolving Status of Prostate Cancer Screening

SOURCE: Bibbins-Domingo K, Grossman DC, Curry SJ. JAMA 2017;317:1949-1950.

The most recent 2017 U.S. Preventive Services Task Force (USPSTF) recommendations regarding prostate cancer screening, which still are open to comment and revision, represent a shift from its “do not screen” statement of 2012. At first glance, the advice may appear to be an “endorsement”; however, one must remember that there are various strengths of endorsement. For instance, the current recommendation boils down to: “Clinicians should inform men aged 55-69 about the potential benefits and harms of screening.” Benefits include about one in 1,000 fewer deaths from prostate cancer and three in 1,000 fewer incidences of metastatic disease when men are followed for 12-13 years. Well-publicized harms include impotence and urinary incontinence.

One’s enthusiasm for the newer, more sanguine recommendations rightly might be damped by noting that this recommendation is graded as “Level C.” What does that mean? In the words of the USPSTF: “The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.”

In other words, each patient must decide whether he is willing to shoulder the risks associated with prostate cancer screening for the possibility that he will be one of the very few men who benefit, which is not an easy call.


Testosterone Replacement: The Limitations of ‘Dr. Google’

SOURCE: McBride JA, Carson CC, Coward RM. Int J Impot Res 2017;29:110-114.

The availability of information at the touch of a finger has become a mixed blessing. Clinicians applaud patients’ efforts to become more involved and informed about their health, but are chagrined about the frequency with which transmission of misinformation occurs.

McBride et al performed a review of websites offering information on hypogonadism by searching the terms “testosterone,” “testosterone therapy,” and “hypogonadism.” Then, the authors performed a quality review on the information supplied by the top 25 websites listed. To keep the subject matter within the most commonly addressed bounds that would be expected to provide relevant information, advertising sites, clinical practice guidelines, and pharmaceutical company websites were omitted. Information was rated for readability (e.g., was the reading level appropriate for most adults), credibility (e.g., who authored the information, references, physician-confirmed medical accuracy, and currency), and quality (e.g., were there links to other educational resources, and were risks as well as benefits appropriately disclosed).

Based on their “internet biopsy,” the authors reached an unfortunate conclusion: Information online was of poor quality and of a complexity level beyond the comprehension of the average patient. Clinicians may have to take a role in directing patients toward high-quality online information.


Send Polycystic Ovary Syndrome Patients to the Dentist?

SOURCE: Kellesarian SV, Malignaggi VR, Kellesarian TV, et al. Int J Impotence Res 2017;29:89-95.

We are becoming progressively enlightened about the intimate relationship between the microbiome (healthy “constitutive” bacteria throughout the body, particularly the gastrointestinal tract) and health. Periodontal disease is a local inflammatory disorder with wide-ranging consequences. It is associated with increased expression of systemic vascular adhesion molecules, tumor necrosis factor, and interleukins. Downstream effects of periodontal disease lead to endothelial dysfunction and have been linked to atherosclerosis, myocardial infarction, stroke, type 2 diabetes, and hypogonadism. This literature review by Kellesarian et al suggested an additional consequence of periodontal disease: polycystic ovary syndrome (PCOS).

Seven case-controlled studies of subjects (n = 770) with PCOS who had undergone evaluation for periodontal health provided the data for evaluation. In each of the studies, a positive association was found between PCOS and periodontal disease.

The link between PCOS and diabetes is well established. These data are limited by the fact that the only available clinical data come from relatively small, short-term trials. Nonetheless, the authors suggested that the consistency of the results (all seven trials found the same positive association) should prompt clinicians to refer PCOS patients for assessment of periodontal health.