1429Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L Department of Urology, Namik Kemal University, Tekirdag, Turkey. Cenk M. Yazici, Cagri Dogan Can Non-Urological Doctors Play a Role in Early Prostate Cancer Detection? Corresponding Author: Cenk M. Yazici, Department of Urology, Namik Kemal Univer- sity, Tekirdag, 59100, Turkey. Tel: +90 506 855 2687 Fax: +90 282 262 4625 E-mail: drcenkyazici@yahoo. com Received August 2012 Accepted February 2013 Purpose:‎To‎evaluate‎the‎awareness‎of‎non-urological‎doctors‎for‎their‎role‎in‎evaluating‎prostate‎ cancer‎(Pca)‎in‎scientific‎manner‎which‎may‎be‎a‎possible‎probability‎for‎late‎diagnosis‎of‎Pca. Materials and Methods:‎A‎total‎of‎936‎non-urological‎specialists‎working‎in‎1‎university‎and‎ 4‎education‎and‎research‎hospital‎who‎were‎able‎to‎evaluate‎male‎patients‎over‎50‎years‎of‎age‎ were‎included‎to‎the‎survey.‎A‎face‎to‎face‎questionnaire‎had‎been‎administered‎to‎all‎participants. Results:‎A‎total‎of‎92‎(9.8%)‎participants‎were‎evaluating‎prostate-specific‎antigen‎(PSA)‎level‎ to‎all‎their‎elderly‎male‎patients‎while‎404‎(43.2%)‎participants‎had‎never‎made‎this‎evaluation.‎ Among‎the‎participants‎who‎were‎evaluating‎PSA,‎none‎was‎performing‎an‎informed‎decision‎ making‎consult‎and‎even‎they‎did‎not‎have‎any‎idea‎about‎the‎meaning‎of‎this‎strategy.‎About‎ the‎criteria‎for‎urological‎consultation,‎56‎(6%)‎reported‎that‎they‎consult‎all‎their‎elderly‎male‎ patients,‎whereas‎880‎(94%)‎answered‎that‎they‎perform‎consultation‎if‎their‎patients‎has‎sought‎ help‎for‎any‎urological‎symptom.‎ Conclusion: Urologists‎must‎remind‎the‎non-urological‎specialists‎that‎their‎approaches‎to‎Pca‎ evaluation‎may‎change‎mortality‎rates‎of‎this‎disease‎and‎give‎them‎proper‎information‎about‎the‎ scientific‎evaluation‎of‎Pca.‎This‎may‎help‎us‎to‎decrease‎the‎mortality‎rates‎of‎Pca.‎ Keywords:‎prostate-specific‎antigen;‎early‎detection‎of‎cancer;‎prostatic‎neoplasms;‎physicians;‎ family‎practice. UROLOGICAL ONCOLOGY 1430 | INTRODUCTION Prostate‎cancer‎(Pca)‎is‎the‎most‎important‎cancer‎of‎male‎population.‎It‎was‎reported‎to‎be‎the‎4th‎most‎common‎cancer‎in‎the‎world‎and‎most‎frequent‎solid‎ tumor‎in‎Europe.(1)‎While‎the‎incidence‎of‎organ‎confined‎ Pca‎has‎increased,‎the‎incidence‎of‎invasive‎or‎metastatic‎ Pca decreased in the last 2 decades. Despite this decrease incidence‎of‎ invasiveness,‎cancer‎specific‎mortality‎rates‎ of‎ Pca‎ did‎ not‎ decline‎ with‎ the‎ same‎ proportion.(2) Pca has‎still‎been‎the‎leading‎cause‎of‎new‎cancer‎cases‎and‎ the‎second‎leading‎cause‎of‎cancer‎deaths‎among‎males‎in‎ United‎States.(3)‎The‎invention‎of‎prostate‎specific‎antigen‎ (PSA)‎was‎a‎cornerstone‎for‎diagnosis‎of‎Pca.(4)‎As‎it‎gave‎ the‎opportunity‎for‎early‎detection‎of‎Pca,‎it‎had‎been‎widely‎ accepted‎all‎around‎the‎world.‎Several‎screening‎programs‎ had‎been‎defined‎to‎provide‎early‎detection‎of‎Pca.‎But‎this‎ programs‎also‎caused‎arguments‎about‎over-diagnosis‎and‎ over-treatments‎for‎patients‎with‎incidental‎Pca.‎Two‎major‎ trials‎evaluating‎the‎effect‎of‎screening‎Pca‎reported‎different‎ results.‎While‎European‎Randomized‎Study‎of‎Screening‎for‎ Prostate‎Cancer‎(ERSPC)‎study‎reported‎a‎beneficial‎effect‎ of‎screening‎on‎mortality‎rates,‎Prostate,‎Lung,‎Colorectal‎ and‎Ovarian‎(PLCO)‎study‎failed‎to‎document‎this‎relation. (5,6)‎Whether,‎screening‎has‎scientific‎manner‎or‎not,‎PSA‎has‎ still‎been‎the‎most‎reliable‎and‎favorable‎tumor‎marker‎for‎di- agnosis‎of‎Pca‎and‎it‎is‎recommended‎to‎perform‎PSA‎evalu- ation‎to‎male‎patients‎over‎50‎years‎of‎age‎after‎a‎decision‎ making‎consult.(7)‎Any‎delay‎in‎performing‎PSA‎to‎elderly‎ patients‎may‎cause‎the‎disease‎progress‎to‎incurable‎stages.‎ In‎most‎developed‎countries,‎general‎practitioners‎(GPs)‎and‎ family‎doctors‎are‎the‎main‎physicians‎that‎have‎first‎contact‎ with‎the‎majority‎of‎patients.‎Their‎view‎for‎Pca‎evaluation‎is‎ thought‎to‎be‎very‎important‎so‎several‎studies‎investigated‎ this issue.(8,9)‎But,‎there‎are‎also‎some‎countries‎that‎other‎ specialists‎may‎be‎the‎primary‎doctor‎of‎patients.‎So,‎those‎ non-urological‎specialists‎may‎be‎the‎first‎doctors‎that‎have‎ the‎opportunity‎ to‎contact‎with‎patients‎and‎evaluate‎Pca.‎ According‎to‎our‎knowledge,‎there‎is‎no‎study‎defining‎the‎ view‎of‎non-urological‎specialist‎in‎evaluation‎of‎Pca.‎In‎this‎ study,‎we‎aimed‎to‎evaluate‎the‎awareness‎of‎non-urological‎ doctors‎for‎the‎evaluation‎of‎Pca‎in‎their‎daily‎work‎life. MATERIALS AND METHODS A‎total‎of‎936‎non-urological‎specialists‎working‎in‎1‎uni- versity‎and‎4‎education‎and‎research‎hospital,‎who‎were‎able‎ to‎evaluate‎male‎patients‎over‎50‎years‎of‎age‎were‎included‎ to‎the‎survey.‎Specialties‎that‎do‎not‎get‎contact‎with‎elderly‎ male‎patients,‎ like‎pediatrician,‎pediatric‎surgeon,‎radiolo- gist‎and‎obstetrics‎and‎gynecologist‎were‎excluded‎from‎the‎ survey.‎All‎other‎specialties‎were‎included‎to‎the‎study.‎The‎ numbers‎of‎participants‎according‎to‎their‎specialties‎were‎ shown‎in‎Table.‎All‎of‎the‎participants‎were‎actively‎work- ing‎at‎outpatient‎clinics‎of‎their‎specialties.‎After‎the‎permis- sion‎of‎local‎ethic‎committee,‎a‎face‎to‎face‎questionnaire‎ including‎a‎written‎consent‎had‎been‎administered‎to‎all‎par- ticipants.‎The‎questionnaire‎was‎composed‎of‎4‎parts‎(Ap- pendix);‎1)‎questions‎about‎the‎demographic‎characteristics‎ of‎participants,‎2)‎questions‎about‎the‎participants’‎approach‎ for‎the‎diagnosis‎of‎Pca‎in‎their‎daily‎work‎life‎such‎as‎PSA‎ evaluation‎ and‎ rectal‎ examination,‎ 3)‎ questions‎ about‎ the‎ general‎knowledge‎of‎participants‎about‎the‎normal‎values‎ of‎total‎PSA,‎and‎4)‎questions‎about‎the‎participants’‎prefer- ences‎for‎urological‎consultations‎and‎family‎history.‎As‎this‎ was‎a‎questionnaire‎study,‎results‎were‎given‎in‎percentages‎ without‎a‎need‎of‎any‎statistical‎analysis.‎ RESULTS All‎of‎the‎doctors‎were‎agreed‎to‎participate‎in‎the‎study.‎ Among‎ the‎ participants,‎ 536‎ (57.3%)‎ were‎ male‎ and‎ 400‎ (42.7%)‎were‎female.‎The‎participants‎were‎evaluating‎92‎±‎ 32‎male‎patients‎over‎50‎years‎of‎age‎in‎one‎month.‎When‎ we‎asked‎the‎frequency‎of‎PSA‎evaluation,‎404‎(43.2%)‎par- ticipants‎told‎that‎they‎never‎evaluate‎this‎marker‎for‎their‎ elderly‎patients.‎Among‎the‎rest‎of‎the‎participants,‎only‎92‎ (9.8%)‎informed‎that‎they‎routinely‎evaluate‎PSA‎for‎their‎ patients‎over‎50‎years‎of‎age.‎A‎total‎of‎312‎(33.3%)‎partici- pants‎declared‎that‎they‎were‎analyzing‎this‎marker‎at‎less‎ than‎half‎of‎their‎patients‎whereas‎128‎(13.7%)‎were‎ana- lyzing‎at‎more‎than‎half‎of‎their‎elderly‎patients‎(Figure,‎A).‎ There‎was‎a‎female‎predominance‎(73.9%)‎at‎the‎group‎who‎ were‎evaluating‎PSA‎at‎their‎whole‎elderly‎patients‎and‎male‎ predominance‎(77.2%)‎at‎the‎group‎who‎were‎never‎evaluat- ing‎PSA.‎Among‎the‎participants‎who‎were‎evaluating‎PSA,‎ none‎was‎performing‎an‎informed‎decision‎making‎consult‎ for‎the‎evaluation‎of‎Pca‎and‎even‎they‎did‎not‎have‎any‎idea‎ about‎the‎meaning‎of‎this‎strategy. To‎the‎question‎related‎to‎abnormal‎value‎of‎total‎PSA,‎36‎ (1.7%)‎participants‎answered‎that‎they‎consider‎it‎as‎abnor- mal‎if‎PSA‎>‎1‎ng/dL,‎168‎(17.9%)‎if‎PSA‎>‎2.5‎ng/dL,‎396‎ Urological Oncology 1431Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L Non-Urological Doctors and Prostate Cancer Detectıon | Yazici et al (42.4%)‎if‎PSA‎>‎4‎ng/dL,‎144‎(15.4%)‎if‎PSA‎>‎10‎ng/dL‎ and‎84‎(9%)‎if‎PSA‎>‎20‎ng/dL.‎A‎total‎of‎128‎(13.6%)‎par- ticipants‎reported‎that‎they‎have‎no‎idea‎about‎the‎normal‎ values‎of‎total‎PSA‎(Figure,‎B).‎Concerning‎the‎physical‎ex- amination,‎816‎(87.2%)‎participants‎reported‎that‎they‎do‎not‎ do‎digital‎rectal‎examination‎(DRE)‎on‎their‎routine‎physical‎ examination‎whereas‎120‎(12.8%)‎told‎that‎they‎do‎it‎rou- tinely.‎Among‎the‎participants‎who‎perform‎DRE,‎64‎were‎ general‎surgeon‎and‎56‎were‎internist.‎When‎we‎asked‎the‎ reason‎of‎non-performing‎DRE,‎680‎(83.3%)‎replied‎that‎it‎ was‎useless‎for‎their‎specialty.‎ When‎we‎asked‎the‎participants‎about‎their‎criteria‎for‎consult- ing‎their‎elderly‎male‎patients‎with‎urologist,‎56‎(6.0%)‎report- ed‎that‎they‎consult‎all‎their‎elderly‎male‎patients,‎whereas‎880‎ (94.0%)‎answered‎that‎they‎seek‎consultation‎if‎their‎patients‎ has‎talked‎about‎any‎urological‎symptom.‎In‎order‎to‎estimate‎ the‎effect‎of‎the‎lower‎urinary‎tract‎symptoms‎on‎PSA‎evalua- tion,‎we‎asked‎“does‎the‎presence‎of‎lower‎urinary‎tract‎symp- toms‎change‎your‎decision‎about‎the‎evaluation‎of‎total‎PSA”?‎ Among‎the‎participants‎who‎never‎evaluate‎PSA,‎396‎(98%)‎ told that it does not change their decision. As‎we‎thought‎that‎the‎evaluation‎of‎Pca‎may‎not‎be‎the‎re- sponsibility‎of‎non-urological‎doctors,‎we‎tried‎to‎demon- strate‎the‎approach‎of‎participants‎to‎Pca‎in‎their‎daily‎life‎ and‎asked‎questions‎about‎their‎fathers.‎A‎total‎of‎52‎(5.5%)‎ participants’‎fathers‎were‎dead‎at‎the‎time‎of‎study‎and‎3‎of‎ them‎had‎a‎history‎of‎Pca.‎One‎of‎the‎participant’s‎fathers‎ was‎ dead‎ because‎ of‎ end-organ‎ failure‎ due‎ to‎ metastatic‎ Pca.‎When‎we‎checked‎the‎approach‎of‎these‎participants,‎ who‎had‎a‎family‎history‎of‎Pca,‎we‎found‎that‎they‎all‎were‎ consulting‎their‎elderly‎male‎patients‎to‎urologists.‎Among‎ the‎rest‎of‎the‎participants,‎828‎(93.6%)‎had‎a‎father‎over‎ 50‎years‎of‎age.‎When‎we‎asked‎them‎if‎they‎performed‎any‎ PSA‎evaluation‎to‎their‎fathers,‎244‎(29.5%)‎replied‎that‎they‎ had‎never‎performed‎PSA‎evaluation‎whereas‎396‎(47.8%)‎ had‎this‎evaluation‎in‎every‎4‎or‎5‎years‎and‎188‎(22.7%)‎had‎ this‎evaluation‎annually‎(Figure,‎C).‎ DISCUSSION Pca‎has‎still‎been‎an‎important‎cause‎of‎cancer‎related‎deaths‎ among‎the‎male‎patients.‎Although‎the‎incidence‎of‎organ‎ confined‎Pca‎had‎increased‎in‎the‎last‎2‎decades,‎disease‎spe- cific‎mortality‎rates‎did‎not‎decrease‎with‎the‎similar‎propor- tion.‎There‎are‎still‎plenty‎of‎patients‎who‎had‎been‎diagnosed‎ at‎invasive‎or‎metastatic‎stage‎and‎lose‎their‎chance‎for‎de- finitive‎treatment.(2)‎So,‎early‎diagnosis‎of‎Pca‎is‎very‎impor- tant‎to‎decrease‎the‎cancer‎related‎mortality‎rates.‎Although‎ there‎have‎been‎debates‎about‎the‎sensitivity‎and‎specificity‎ of‎PSA‎for‎Pca‎screening,‎it‎has‎still‎been‎the‎most‎reliable‎ and‎useful‎tumor‎marker‎for‎diagnosis‎of‎Pca.(5,6) When it is combined‎with‎digital‎rectal‎examination,‎its‎sensitivity‎and‎ specificity‎for‎diagnosing‎Pca‎increases.(10) After‎the‎publication‎of‎2‎major‎randomized‎trials‎(ERSPC‎ and‎PLCO‎trials),‎screening‎protocols‎for‎Pca‎became‎a‎con- troversial‎issue.(5,6)‎General‎idea‎formed‎about‎this‎subject‎ is‎to‎perform‎PSA‎evaluation‎with‎the‎decision‎of‎patients‎ after‎ an‎ informed‎ decision‎ making‎ consult.‎ On‎ the‎ other‎ hand,‎there‎is‎little‎evidence‎about‎how‎to‎organize‎services‎ to‎achieve‎the‎best‎informed‎decision.‎In‎developed‎countries‎ with‎a‎well-accomplished‎health‎policy,‎general‎practitioners‎ and‎family‎doctors‎are‎the‎primary‎doctors‎that‎get‎contact‎ with‎a‎large‎proportion‎of‎the‎population‎and‎could‎play‎an‎ important‎role‎in‎informed‎decision‎making‎consult,‎but‎there‎ are‎also‎some‎countries‎that‎non-urological‎specialists‎other‎ than‎GPs‎and‎family‎doctors‎could‎be‎the‎main‎doctor‎that‎ get‎first‎contact‎with‎patients.‎So,‎they‎could‎assume‎a‎role‎in‎ preventive‎effort‎of‎Pca.‎For‎this‎reason,‎non-urological‎doc- tors‎must‎be‎aware‎of‎one‎of‎the‎most‎important‎cancer‎type‎ of‎elderly‎male‎patients‎and‎understand‎their‎possible‎role‎in‎ Figure. The ratios of general answers to the questionnaire. 1432 | the‎campaign‎against‎this‎cancer.‎ There‎are‎some‎studies‎evaluating‎the‎view‎of‎GPs‎and‎fam- ily‎doctors‎to‎Pca‎evaluation‎and‎screening.‎Melia‎and‎col- leagues‎reported‎that‎annual‎PSA‎testing‎ratio‎among‎GPs‎in‎ England‎was‎6%‎in‎symptomatic‎and‎2%‎in‎asymptomatic‎ elderly‎ male‎ patients.(11)‎ On‎ the‎ other‎ hand,‎ Hudson‎ and‎ colleagues‎ reported‎ much‎ higher‎ ratios‎ (77%)‎ of‎ evaluat- ing‎PSA‎among‎American‎GPs.(3)‎These‎two‎studies‎from‎ different‎countries‎with‎different‎results‎reported‎the‎simi- lar‎conclusion‎that‎informed‎decision‎making‎has‎yet‎to‎be‎ incorporated‎as‎a‎routine‎part‎of‎primary‎care‎practice.‎We‎ also‎agree‎with‎this‎conclusion‎and‎we‎think‎that,‎not‎only‎ GPs‎and‎family‎doctors‎take‎role‎in‎informed‎decision‎mak- ing‎ consult‎ about‎ Pca,‎ non-urological‎ specialist‎ may‎ also‎ have‎role‎in‎this‎issue.‎For‎this‎reason,‎evaluating‎the‎view‎of‎ non-urological‎specialist‎to‎Pca‎may‎be‎important‎for‎strat- egy‎planning‎against‎this‎mortal‎disease.‎According‎to‎our‎ knowledge‎this‎is‎the‎first‎study‎in‎literature‎evaluating‎the‎ view‎of‎non-urological‎specialist‎to‎evaluation‎of‎Pca.‎ In‎our‎study,‎only‎9.8%‎of‎non-urological‎specialists‎reported‎ that‎they‎do‎PSA‎evaluation‎to‎all‎of‎their‎elderly‎male‎pa- tients,‎whereas‎43%‎of‎participants‎reported‎that‎they‎never‎ perform‎this‎evaluation.‎Beside‎this,‎94%‎of‎participants‎de- clared‎that‎they‎don’t‎seek‎any‎urological‎consultation‎for‎ their‎elderly‎male‎patients‎unless‎patients‎have‎talked‎about‎ their‎urological‎symptoms.‎As‎none‎of‎our‎participants‎was‎ talking‎about‎the‎risks‎of‎Pca‎to‎their‎elderly‎patients,‎they‎ were‎not‎taking‎any‎role‎in‎informed‎decision‎making‎consult‎ for‎Pca‎evaluation.‎Even‎if‎we‎think‎that‎these‎patients‎do‎ not‎have‎any‎urological‎symptom‎and‎did‎not‎visit‎an‎urolo- gist,‎these‎doctors‎will‎be‎the‎only‎opportunity‎for‎patients‎ for‎early‎detection‎of‎Pca.‎Their‎approach‎to‎these‎patients‎ may‎cause‎a‎delay‎in‎diagnosis‎of‎Pca‎and‎may‎let‎the‎disease‎ progress to an incurable stage. Digital‎rectal‎examination‎is‎one‎part‎of‎the‎main‎urologi- cal‎examination.‎In‎about‎18%‎of‎patients‎with‎Pca‎can‎be‎ detected‎by‎an‎abnormal‎DRE,‎irrespective‎of‎PSA‎level.(12)‎ For‎this‎reason,‎DRE‎is‎very‎important‎for‎diagnosis‎of‎Pca.‎ Urologists‎are‎not‎the‎only‎specialists‎that‎perform‎DRE‎in‎ their‎daily‎practice.‎General‎surgeons‎and‎internal‎medicine‎ doctor‎also‎perform‎DRE‎normally‎in‎their‎daily‎practice.‎ According‎to‎our‎study,‎nearly‎80%‎of‎internal‎medicine‎doc- tors‎and‎35%‎of‎general‎surgeons‎were‎not‎performing‎DRE.‎ Beside‎this,‎87%‎of‎specialists‎in‎our‎study‎population‎were‎ not‎performing‎DRE.‎Indeed,‎DRE‎is‎not‎a‎routine‎examina- tion‎for‎some‎specialties,‎but‎to‎be‎aware‎of‎the‎importance‎ of‎this‎examination‎may‎help‎to‎guide‎the‎patient‎for‎basic‎ Pca‎screening.‎Urologists‎may‎provide‎this‎by‎close‎contact‎ with‎their‎colleagues‎informing‎them‎about‎the‎importance‎ of‎DRE. Nearly‎all‎participants‎told‎that,‎evaluation‎of‎Pca‎was‎not‎ the‎responsibility‎of‎non-urological‎doctors.‎This‎may‎be‎an‎ explanation‎for‎them‎not‎to‎evaluate‎PSA‎for‎their‎elderly‎ patients.‎On‎the‎other‎hand,‎nearly‎70%‎of‎our‎participants‎ reported‎that‎they‎performed‎PSA‎evaluation‎for‎their‎fathers.‎ This‎data‎shows‎that‎our‎participants‎were‎mostly‎aware‎of‎ the‎importance‎of‎Pca,‎but‎they‎do‎not‎pay‎attention‎to‎this‎ subject‎in‎their‎daily‎work‎life.‎Urologists‎must‎be‎aware‎of‎ this‎fact‎and‎encourage‎the‎non-urological‎doctors‎for‎deci- sion‎making‎consult‎for‎Pca‎diagnosis‎or‎consulting‎their‎el- derly‎patients‎to‎urologists‎for‎evaluation‎of‎Pca.‎ In‎order‎to‎accomplish‎this‎purpose‎we‎must‎explain‎the‎non- urological‎doctors‎that,‎they‎may‎have‎opportunity‎to‎see‎el- derly‎male‎patients‎that‎had‎never‎been‎seen‎by‎an‎urologist.‎ Table. The number of participants according to specialties. Specialty Number Specialty Number Emergency Medicine 12 Family Medicine 44 Neurosurgery 24 Internal Medicine 240 Dermatology 36 Physical Rehabilitation 28 General Surgery 92 Ophthalmology 92 Cardiology 64 Otolaryngology 96 Neurology 76 Plastic Surgery 32 Psychiatry 32 Orthopedics 28 Cardiovascular Surgery 20 Thoracic Surgery 20 Total number 936 Urological Oncology 1433Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L So‎a‎non-urological‎specialist‎may‎be‎the‎only‎doctor‎that‎is‎ able‎to‎reach‎and‎evaluate‎those‎patients‎and‎these‎visits‎may‎ be‎very‎important‎to‎eliminate‎the‎doctor‎related‎delay‎on‎ the‎diagnosis‎of‎Pca.‎For‎this‎purpose,‎non-urological‎doc- tors‎must‎be‎aware‎of‎one‎of‎the‎most‎common‎cancer‎type‎ of‎elderly‎male‎patients‎and‎understand‎their‎possible‎role‎for‎ early‎detection‎of‎Pca.‎This‎role‎can‎be‎achieved‎by‎a‎simple‎ PSA‎determination‎after‎a‎brief‎informed‎decision‎making‎ consult‎at‎patients‎who‎did‎not‎have‎any‎urological‎evalua- tion. There‎were‎some‎limitations‎in‎present‎study.‎First‎of‎all,‎ this‎was‎a‎questionnaire‎based‎study‎performed‎to‎a‎limited‎ number‎of‎non-urological‎doctors‎and‎may‎not‎be‎enough‎ to‎generalize‎to‎all‎non-urological‎doctors.‎Beside‎this,‎we‎ were‎not‎able‎to‎reach‎past‎medical‎records‎to‎confirm‎the‎ rates‎of‎PSA‎evaluation‎of‎participants.‎We‎also‎did‎not‎have‎ any‎idea‎about‎the‎number‎of‎patients‎who‎were‎evaluated‎by‎ non-urological‎doctors‎but‎had‎not‎evaluated‎by‎urologists.‎ So‎we‎cannot‎identify‎the‎possible‎Pca‎risk‎of‎elderly‎patients‎ who‎were‎seen‎by‎non-urological‎patients.‎Our‎study‎was‎de- signed‎on‎a‎theory‎that‎non-urological‎doctors‎do‎not‎evalu- ate‎and‎inform‎their‎elderly‎patients‎about‎Pca.‎This‎study‎ may‎show‎the‎relation‎but‎may‎not‎be‎enough‎to‎prove‎this‎ theory‎and‎more‎comprehensive‎studies‎are‎needed.‎Another‎ issue‎about‎this‎subject‎is;‎we‎evaluated‎the‎non-urological‎ doctors‎who‎work‎in‎teaching‎or‎university‎hospitals.‎These‎ findings‎may‎not‎reflect‎the‎real‎practice‎in‎peripheral‎health‎ units,‎but‎there‎is‎another‎fact‎that‎Pca‎mortality‎rates‎did‎not‎ decrease although the diagnosis rates increased by the last 2‎decades.‎This‎shows‎that‎there‎is‎still‎a‎problem‎in‎early‎ detection‎of‎Pca.‎ CONCLUSION As‎a‎conclusion,‎campaigns‎against‎important‎diseases‎need‎ a‎team‎work‎including‎doctors,‎health‎personals‎and‎media.‎ We‎must‎remember‎that‎non-urological‎doctors‎are‎the‎mem- bers‎of‎the‎team‎against‎Pca.‎We‎must‎remind‎them‎that‎their‎ approaches‎to‎Pca‎evaluation‎may‎change‎mortality‎rates‎of‎ this‎disease‎and‎give‎them‎proper‎information‎about‎the‎sci- entific‎evaluation‎of‎Pca.‎This‎may‎help‎us‎to‎decrease‎the‎ mortality‎rates‎of‎Pca.‎ CONFLICT OF INTEREST None declared. Non-Urological Doctors and Prostate Cancer Detectıon | Yazici et al REFERENCES 1. Boyle P, Ferlay C. Cancer incidence and mortality in Europe 2004. Ann Oncol. 2005;16:481-8. 2. Quinn M, Babb P. Patterns and trends in prostate cancer incidence, survival, prevalence and mortality. Part I: International compari- sons. Br J Urol Int. 2002;90:162-73. 3. Hudson SV, Ohman-Strickland P, Ferrante JM, Lu-Yao G, Orzano AJ, Crabtree BF. Prostate-specific antigen testing among the elderly in community-based family medicine practices. J Am Board Fam Med. 2009;22:257-65. 4. Stamey TA, Yang N, Hay AR, McNeal JE, Freiha FS, Redwine E. Pros- tate-specific antigen as a serum marker for adenocarcinoma of the prostate. N Engl J Med. 1987;317:909-16. 5. Andriole GL, Crawford ED, Grubb RL et al. PLCO Project Team. Mor- tality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009;360:1797. 6. Schröder FH, Hugosson J, Roobol MJ, et al. ERSPC Investigators. Screening and prostate-cancer mortality in a randomized Euro- pean study. N Engl J Med. 2009;360:1320-8. 7. De la Rosette J, Alivizatos G, Madersbacher S, et al. EAU Guidelines on Benign Prostatic Hyperplasia 2006. p. 13-14. 8. Melia J, Moss S. Survey of the rate of PSA testing in general practice. Br J Cancer. 2001;85:656-7. 9. Williams N, Hughes LJ, Turner EL, et al. Prostate-specific antigen testing rates remain low in UK general practice: a cross-sectional study in six English cities. BJU Int. 2011;108:1402-8. 10. Catalona WJ, Richie JP, Ahmann FR, et al. Comparison of digital rec- tal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6630 men. J Urol. 1994;151:1283-90. 11. Melia J, Moss S, Johns L. Contributors in the participating laborato- ries. Rates of prostate-specific antigen testing in general practice in England and Wales in asymptomatic and symptomatic patients: a cross-sectional study. BJU Int. 2004;94:51-6. 12. Richie JP, Catalona WJ, Ahmann FR, et al. Effect of patient age on early detection of prostate cancer with serum prostate-specific an- tigen and digital rectal examination. Urology. 1993;42:365-74. 1434 | Appendix. Questionnaire for evaluation of the view of non-urological doctors to prostate cancer. Gender:‎ ‎ Female‎□‎ Male‎□‎ Specialty: 1.‎How‎many‎male‎patients‎over‎50‎years‎of‎age‎do‎you‎eval- uate‎in‎a‎month‎period‎at‎your‎outpatient‎clinic?‎ 2.‎How‎frequent‎do‎you‎evaluate‎total‎PSA‎level‎of‎your‎pa- tients‎over‎50‎years‎of‎age?‎ a.‎None‎(I‎do‎not‎evaluate‎total‎PSA)‎ b.‎<‎50%‎patients c.‎50%‎patients d. All patients 3.‎Do‎you‎have‎any‎idea‎about‎informed‎decision‎making‎for‎ PSA‎screening? a.‎Yes‎(please‎specify‎what‎does‎it‎mean‎for‎you)? b. No, I did not hear about it. 4.‎If‎you‎are‎evaluating‎total‎PSA,‎do‎you‎give‎any‎infor- mation‎about‎prostate‎cancer‎and‎possible‎risks‎of‎screening‎ total‎PSA? a.‎Yes,‎I‎inform‎all‎my‎patients. b.‎Yes,‎I‎inform‎some‎of‎my‎patients. c.‎No,‎I‎do‎not‎give‎any‎information. 5.‎(For‎the‎participant‎who‎replied‎“none”‎to‎the‎first‎ques- tion).‎Does‎ the‎presence‎of‎ lower‎urinary‎ tract‎symptoms‎ change‎your‎decision‎for‎evaluating‎total‎PSA‎level? a.‎Yes b. No 6.‎Which‎total‎PSA‎level‎do‎you‎consider‎to‎be‎abnormal‎and‎ consult‎to‎an‎urologist? ‎‎ a.‎PSA‎>‎1‎ng/dL ‎‎ b.‎PSA‎>‎2.5‎ng/dL ‎‎ c.‎PSA‎>‎4‎ng/dL ‎‎ d.‎PSA‎>‎10‎ng/dL ‎‎ e.‎PSA‎>‎20‎ng/dL ‎‎ f.‎I‎do‎not‎have‎any‎idea.‎ 7.‎Do‎you‎perform‎digital‎rectal‎examination‎to‎your‎male‎ patients‎over‎50‎years‎of‎age‎in‎your‎daily‎practice? a.‎Yes‎I‎perform‎this‎examination‎routinely.‎ b.‎Sometimes‎(please‎specify). c.‎No,‎I‎never‎perform‎this‎examination. 8.‎If‎you‎do‎not‎perform‎digital‎rectal‎examination,‎would‎ you‎please‎specify‎the‎reason? 9.‎Do‎you‎consider‎seeking‎a‎urological‎consultation‎for‎your‎ male‎patients‎over‎50‎years‎of‎age?‎ a.‎Yes,‎I‎consult‎all‎male‎patients‎over‎50‎years‎of‎age. b.‎I‎consult‎male‎patients‎over‎50‎years‎of‎age‎in‎some‎con- siderations‎(please‎specify). c.‎No,‎I‎never‎consult‎male‎patients‎over‎50‎years‎of‎age.‎ 10.‎What‎is‎the‎age‎of‎your‎father?‎(If‎your‎father‎is‎dead‎ please‎note‎the‎reason). 11.‎Did‎you‎perform‎total‎PSA‎evaluation‎to‎your‎father? a.‎No,‎I‎did‎not‎make‎total‎PSA‎evaluation‎to‎my‎father. b.‎Yes,‎I‎do‎total‎PSA‎evaluation‎every‎year. c.‎Yes,‎I‎do‎total‎PSA‎evaluation‎in‎every‎_______‎years.‎ Thank‎you‎for‎your‎kind‎participation. Urological Oncology