Effect of long term tamoxifen treatment on bone turnover in women with breast cancer.

Great pressure has recently been put on clinicians by hospital managers and politicians to reduce waiting times. Unfortunately, the emphasis of current initiatives on waiting lists tends to be on reducing the wait for surgery rather than the waiting time for an appointment at an outpatient clinic. We report the potential dangers of long waiting times for a routine outpatient appointment at a urology clinic. Over the past three years 55 patients with symptoms of bladder outflow obstruction were recruited for two clinical trials. These patients were recruited from the waiting list of new patients which comprised patients who had been classified as having routine conditions by the consultant on the basis of the information in the referral letter. Recruitment into the trials depended on patients satisfying the entry criteria and giving their informed consent. The protocols for the trials were approved by the ethical committee. The average wait for these patients who were seen outside the normal times of outpatient clinics, was 13 (range 3-104) weeks. All patients gave a full medical history and had a full examination, and routine investigations for bladder outflow obstruction were performed. One trial (25 patients) also required transrectal ultrasonography of the prostate and a serological test for prostate specific antigen whereas the other (30 patients) required further investigation only if malignancy was suspected clinically. During our investigation of these patients, we diagnosed seven new cases of cancer of the prostate. These were detected by rectal examination (five), a raised concentration of prostate specific antigen (one), and transrectal ultrasonography (one). Four of these cancers were well or moderately well differentiated, and five of the six bone scans obtained yielded negative results. A superficial cancer of the bladder was detected during transrectal ultrasonography of the prostate and a caecal cancer was found on barium enema examination in a patient with iron deficiency anaemia. In four patients a history of haematuria was elicited for the first time and was investigated. Ultrasonography also detected one case of chronic retention of urine with overflow. Comment This study highlights the prevalence of associated disease in patients who were classed as having routine bladder outflow obstruction. The average wait for a routine appointment at our department's outpatient clinic was eight months, with a further wait of two years for a prostatectomy. A random poll of 16 departments of urology was conducted by means of a telephone conversation with each consultant's …