Diagnostic value of systematic biopsy methods in the investigation of prostate cancer: a systematic review.

PURPOSE: Several new extended prostate biopsy schemes (greater than 6 cores) have been proposed. We compared the cancer detection rates and complications of different extended prostate biopsy schemes for diagnostic evaluation in men scheduled for biopsy to identify the optimal scheme. MATERIALS AND METHODS: In a systematic review we searched 13 electronic databases, screened relevant urological journals and the reference lists of included studies, and contacted experts. We included studies that compared different systematic prostate biopsy methods using sequential sampling or a randomized design in men scheduled for biopsy due to suspected prostate cancer. We pooled data using a random effects model when appropriate. RESULTS: We analyzed 87 studies with a total of 20,698 patients. We pooled data from 68 studies comparing a total of 94 extended schemes with the standard sextant scheme. An increasing number of cores were significantly associated with the cancer yield. Laterally directed cores increased the yield significantly (p = 0.003), whereas centrally directed cores did not. Schemes with 12 cores that took additional laterally directed cores detected 31% more cancers (95% CI 25 to 37) than the sextant scheme. Schemes with 18 to 24 cores did not detect significantly more cancers. Adverse events for schemes up to 12 cores were similar to those for the sextant pattern. Adverse event reporting was poor for schemes with 18 to 24 cores. CONCLUSIONS: Prostate biopsy schemes consisting of 12 cores that add laterally directed cores to the standard sextant scheme strike the balance between the cancer detection rate and adverse events. Taking more than 12 cores added no significant benefit.

Assessing the cost-effectiveness of new pharmaceuticals in epilepsy in adults: the results of a probabilistic decision model.

Epilepsy currently affects more than 400,000 people in the United Kingdom and 2.3 million in the United States. Drug therapy is the mainstay of treatment for patients with epilepsy, but therapies vary widely in their mechanism of action and acquisition cost. This article describes a decision model developed for the National Institute for Clinical Excellence in the United Kingdom. It compares the long-term cost-effectiveness of drugs licensed in adults for use in 3 situations: monotherapy for newly diagnosed patients, monotherapy for refractory patients, and combination therapy for refractory patients. The analysis separately considers the treatment of partial and generalized seizures. The full range of pharmaceutical therapies feasibly used in the UK health system was included in the analysis. The analysis showed that, on the basis of existing evidence, for newly diagnosed patients with partial seizures, carbamazepine and valproate are likely to be the most cost-effective mono-therapies. Carbamazepine is likely to be the most cost-effective 2nd-line monotherapy for refractory patients, and oxcarbazepine would probably be the most cost-effective adjunctive therapy for refractory patients if the willingness to pay for additional health benefits is greater than 18,000 pounds per quality-adjusted life year (QALY). For patients with generalized seizures, valproate is most likely to be cost-effective for newly diagnosed patients. For refractory patients, adjunctive topiramate is more cost-effective than monotherapy alone if the willingness to pay for additional health benefits is greater than 35,000 pounds per QALY. There is, however, considerable uncertainty regarding these results. Some of the methodological features of the study will be of value in designing cost-effectiveness analyses of other therapies for chronic conditions. These include the methods used to deal with the absence of head-to-head trial data and the need to reflect time dependency in Markov transition probabilities.