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PSA tests best link to prevention
In the late 1990s, for the first time, the death rate from prostate cancer dropped slightly. "We believe it is a direct result of mass screenings and also from men getting prostate-specific antigen [PSA] tests and rectal exams annually on their own," says Tim Wilson, MD, director of urology/urologic oncology at City of Hope National Medical Center in Duarte, CA.
Screenings make sense because prostate cancer is one of the most common cancers in men with around 200,000 cases diagnosed each year, says Wilson.
About 40,000 men die from prostate cancer annually because it is not diagnosed early enough. If caught at an early stage, prostate cancer is treatable.
Mass screenings started in 1990 when PSA tests became available for widespread use. The abnormal range for a PSA test is about the level of 4.0. If the PSA test is between 4.0 and 10, there is a 30% chance the patient has prostate cancer. "PSA is probably the best screening test there is for any one cancer, but it is not perfect," explains Wilson. Along with the PSA test, a screening consists of a rectal examination where a physician feels the prostate for lumps that might be suspicious.
Schedule screenings at memorable times
City of Hope has offered free prostate cancer screening exams for about 10 years. The screenings are usually held during September because Prostate Cancer Awareness Week falls in that month. This time slot makes sense because there is a lot of media attention on prostate cancer, and men are more likely to take advantage of screening programs, says Judy Brent, RN, BSN, a nurse manager at City of Hope and coordinator of the screening program. The medical facility limits registration to 300 men due to cost and logistic factors and never has trouble filling the slots.
Tying the screenings to a date connected with men makes sense, agrees Patrick DiMeo, BSN, RN, OCN, nursing staff development coordinator at the James Cancer Hospital and Solove Research Institute in Columbus, OH. This institution has held screenings in September for years, but is considering switching to June in honor of Father’s Day in hopes that loved ones will encourage their dad or grandpa to be tested.
In addition to coordinating the prostate cancer screenings at the James Cancer Hospital, DiMeo frequently speaks to men’s groups about prostate cancer and the importance of being screened. "If men are feeling well, they often see no reason to get checked, so we have to change their mindset. I tell them that if it is at a very localized stage, their five-year survival rate is 100%," says DiMeo. When men begin to experience signs and symptoms, the cancer is usually at a later stage.
The James Cancer Hospital also sponsors educational events called "The Boys Night Out," when men are invited to an organized talk about prostate cancer, its risk factors, signs and symptoms, screening and detection, and treatment options. The event is publicized via newspaper ads and flyers sent to men’s organizations in the area where the talk will take place. The talks are held at hotel conference rooms or large public facilities like senior citizen centers.
Organization key to screening success
While education helps prompt men to be screened for prostate cancer, the screenings themselves must be well-organized to be successful and beneficial. Following are a few steps that should be a part of the screening process:
• Make screenings convenient.
City of Hope usually schedules prostate cancer screenings for two evenings during the week so men can drop by the clinic after work and on one Saturday. A first-floor suite of one of the outpatient clinics is used for the screenings so people can easily find the location.
• Get the word out.
City of Hope has found that the best way to get the word out to the community is to place ads in newspapers. Also, they use the list of men from the previous screening roster to send direct-mail ads.
In addition to newspaper ads, James Cancer Hospital publicizes the screening in its prostate cancer support group so that the men will tell their friends and family. The screening also is promoted during special events at the hospital.
• Schedule appointments.
Both the James Cancer Hospital and City of Hope provide a special number for men to call to schedule a time for their prostate cancer screening. "The reason we schedule appointments is so that we don’t have an overabundance of people coming at one time and also because a physician’s time is precious and we don’t want them idle because no one showed up," says DiMeo.
While the James allows walk-in participants and fits them in during the times staff have a little down time, City of Hope does not. City of Hope schedules 300 appointments seeing seven men every 15 minutes. The volume is based on the number of screenings the physicians and lab staff are able to handle.
In addition to good use of time, scheduled appointments also provide an opportunity to screen participants in advance and gather some of the demographic information needed, which cuts down on paperwork at the screening site.
Those who need to be screened for prostate cancer are all men age 50 and older, men age 40 and older with a family history of prostate cancer, and African-American men who are at least 40 years old. "As men get older, their risk is increased. For men ages 40-59, the risk for prostate cancer is one in 53. One in seven men age 60-70 will get prostate cancer," says DiMeo.
New patient services staff answer the phone calls for appointments at City of Hope and before scheduling the men for a screening, they make sure they fit the criteria. The person scheduling the appointment also gathers some demographic information such as address, race, height, weight, and name and address of personal physician. Men also are told to arrive promptly for their scheduled appointment.
Make screening worthwhile
• Supply adequate exam information.
When men check in for their prostate cancer screening at City of Hope, they are asked to complete a short medical history form. Information gathered includes date of last rectal exam, date and results of last PSA, history of prostate infection, enlarged prostate, prostate surgery, prostate cancer, medications for prostate problems, and whether the patient has a father or brother with prostate cancer. Men are asked to rate several questions on a scale of zero to five, with zero being never and five being always. These questions include:
— Do you stop and start again while urinating?
— Do you find it difficult to postpone urination?
— Do you have a weak urinary stream or have to push or strain to start urination?
— Do you have any blood or pus in your urine?
— Any blood in semen?
— Do you get up frequently during the night to urinate?
The physician goes over the history with the patient before completing the rectal exam, says Brent.
• Provide good follow-up.
At City of Hope, a form the physician attaches to the patient’s history has an area to write the results of the rectal exam along with impressions and comments. A diagram of the prostate gives the physician an opportunity to indicate an area that feels abnormal, if there is one. Patients are given the results of the rectal exam at the time of the screening with recommendations to see a urologist, continue to have an annual exam, or perhaps begin taking certain medications. "The recommendations vary from person to person," says Brent.
Patients are mailed the results of their PSA tests four to six weeks following the screening. Wilson and Brent went through the results of all 297 (three were no shows) men screened last year and attached an appropriate form letter when necessary indicating the rectal exam revealed abnormalities, the PSA was elevated, or both.
"Because some of the men had taken part in our prostate screening in years past, we had those results; and if we began to see a trend where the PSA was still normal but steadily increasing each year, the physician would write a letter advising the patient to seek follow-up," says Brent.
• Make education materials available.
When men come in for their screening at the James Cancer Hospital, they are given a packet of educational handouts on prostate cancer. If DiMeo is available at the time, he will go over the information with the patients and see if they have questions, although some don’t want to discuss prostate cancer unless they are diagnosed with it. If only volunteers are staffing the check-in desk, then the patient is simply given the packet. "It’s best if we are able to talk with them about the information rather than just handing it to them to read because they may not comprehend everything," says DiMeo.
At City of Hope, a table with information on prostate screening and prostate cancer is available.
• Secure funding to cover expenses.
All those who are part of the prostate cancer screenings at City of Hope are asked to be resourceful, from the public relations department who publicize the screening to the lab that conducts the PSA tests, says Brent. For example, a lab technician last year got a company to donate PSA kits worth $5,000, and the urologists donated their time. Pharmaceutical companies often are willing to donate money for publicity, adds Brent.
• Don’t be held liable.
Every individual who participates in the prostate cancer screenings at City of Hope fills out a consent form. The form explains the prostate cancer screening program, the procedure, when results are available, and releases the medical facility from liability and medical claims. "It is a standard procedure here," says Brent.
Are prostate cancer screening programs worth the effort? Last year, 21% of the men screened at City of Hope had an abnormality of some sort. The James Cancer Hospital averages between 40 and 150 screenings each year and saw 75 men last year. Each year, they have found at least one case of prostate cancer and a maximum of five cases. However, one of the most important benefits of the screening is the increased awareness of the importance of being checked, says DiMeo. n
For more information on organizing prostate cancer screenings, contact:
• Judy Brent, RN, BSN, Nurse Manager, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010. Telephone: (626) 359-8111, ext. 65252. E-mail: Brent_Judy@smtplink.coh.org.
• Patrick DiMeo, BSN, RN, OCN, Nursing Staff Development Coordinator, James Cancer Hospital and Solove Research Institute, 300 W. 10th Ave., 004, Columbus, OH, 43210. Telephone: (614) 293-4646. E-mail: firstname.lastname@example.org.
• Tim Wilson, MD, Director of Urology/Urologic Oncology, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010. Telephone: (626) 359-8111, ext. 62655. E-mail: email@example.com.
• Prostate Cancer Awareness Week, Sept. 16-22, American Cancer Society, 1599 Clifton Road N.E., Atlanta, GA 30329. Telephone: (800) 227-2345 or (404) 320-3333.