Long-Term Impact of Medicaid Expansion on Prostate Cancer Screening

INTRODUCTION

Prostate cancer is the most common noncutaneous malignancy in men. The updated PSA testing 2018 United States Preventive Services Task Force guidelines recommend shared decision-making for men ages 55 to 69. In 2010, the Affordable Care Act expanded Medicaid coverage to childless adults earning < 138% of the federal poverty level. Thereafter, individual states have chosen to adopt or defer Medicaid expansion at different times. This allows for the opportunity to study the effects of expansion on a population that did not previously qualify for Medicaid. We examine the long-term association of Medicaid expansion on prostate cancer screening.

METHODS

Data from the Behavioral Risk Factor Surveillance System were extracted for childless men earning less than 138% of the federal poverty level in states with different Medicaid expansion statuses from 2012 to 2020. States were classified into 4 expansion categories: very early expansion states, early expansion states, late expansion states, and nonexpansion states. Prevalence of PSA screening was determined for each category of expansion. Difference-in-difference analyses were used to understand variations in very early expansion states, early expansion states, and late expansion states trends with reference to nonexpansion states.

RESULTS

PSA screening prevalence decreased in very early expansion states (27.76% vs 18.50%), early expansion states (33.79% vs 18.09%), late expansion states (36.08% vs 19.14%), and nonexpansion states (38.82% vs 24.40%) from 2012 to 2020. However, the difference-in-difference analyses did not show statistically significant results among any of the years and expansion category groups in our study period.

CONCLUSIONS

PSA screening prevalence decreased in all states, regardless of expansion category. No long-term effect of Medicaid expansion on PSA screening prevalence was observed among states with different expansion statuses.

Racial differences in patient-reported outcomes among men treated with radical prostatectomy for prostate cancer

BACKGROUND

Real-world data on racial differences in the side effects of radical prostatectomy on quality of life (QoL) are lacking. We aimed to evaluate differences in patient-reported outcome measure (PROM) among non-Hispanic Black (NHB) and non-Hispanic White (NHW) men using the Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP) questionnaire to measure health-related QoL after radical prostatectomy.

METHODS

We retrospectively assessed prospectively collected PROMs using EPIC-CP scores at a tertiary care center between 2015 and 2021 for men with prostate cancer undergoing radical prostatectomy. The primary endpoint was the overall QoL score for NHB and NHW men, with a total score of 60 and higher scores indicating worse QoL. An imputed mixed linear regression model was used to examine the effect of covariates on the change in overall QoL score following surgery. A pairwise comparison was used to estimate the mean QoL scores before surgery as well as up to 24 months after surgery.

RESULTS

Our cohort consisted of 2229 men who answered at least one EPIC-CP questionnaire before or after surgery, of which 110 (4.94%) were NHB and 2119 (95.07%) were NHW men. The QoL scores differed for NHB and NHW at baseline (2.34, 95% confidence interval [CI] 0.36-4.31, p = 0.02), 3 months (4.36, 95% CI 2.29-6.42, p < 0.01), 6 months (3.26, 95% CI 1.10-5.43, p < 0.01), and 12 months after surgery (2.48, 95% CI 0.19-4.77, p = 0.03) with NHB having worse scores. There was no difference in QoL between NHB and NHW men 24 months after surgery.

CONCLUSIONS

A significant difference in QoL between NHB and NHW men was reported before surgery, 3, 6, and 12 months after surgery, with NHB having worse QoL scores. However, there was no long-term difference in reported QoL. Our findings inform strategies that can be implemented to mitigate racial differences in short-term outcomes.

Clinical stage and grade migration of localized prostate cancer at diagnosis during the past decade

OBJECTIVES

Early 2010s data suggest a reverse stage and grade migration towards more aggressive prostate cancer (PCa) at diagnosis, accelerated by the 2012 US Preventive Services Task Force recommendation against PSA screening. Using the National Cancer Database, we investigated the impact of the 2018 USPSTF recommendation and the COVID-19 outbreak on this shift. We hypothesized that the COVID-19 outbreak would further contribute to a stage and grade migration towards more aggressive disease.

MATERIAL AND METHODS

We identified men with localized PCa diagnosed between 2010 and 2020. We analyzed the shift in the proportion of PCa stratified according to D'Amico risk classification. We used multivariable logistic regression models to assess the association between year of diagnosis and dichotomous variables related to clinical stage and grade of PCa. Predicted probabilities with 95% CI were computed through marginal effect analyses.

RESULTS

We identified 910,898 men with localized PCa. The proportion of low-risk PCa almost halved from 34.9% in 2010 to 17.7% in 2020 (P < 0.001). Compared to 2010, we found in each year increased odds of: PSA≥10 ng/dL starting from 2012 (aOR2012 1.05; 95% CI, 1.02-1.08); cT3-T4 starting from 2015 (aOR2015 1.10; 95% CI, 1.03-1.17); ISUP GG 3-5 starting from 2011 (aOR2011 1.06; 95% CI, 1.03-1.08); and consequently, D'Amico intermediate/high-risk class starting from 2011 (aOR2011 1.03; 95% CI, 1.01-1.05). Fluctuations in the probabilities of PSA≥10 ng/dL and cT3-T4 at diagnosis were observed over time (all P < 0.001). The probability of PSA≥10 ng/dL peaked at 29.0% (95% CI, 28.0%-29.0%) in 2018, while the probability of cT3-T4 peaked at 3.7% (95% CI, 3.6%-3.8%) in 2020. All other outcome variables demonstrated a consistent upward shift (all P < 0.001), with the highest probabilities in 2020 for ISUP GG 3-5 (42.3%, 95% CI, 41.9%-42.6%) and D'Amico intermediate/high-risk (81.3%, 95% CI, 81.0%-81.6%).

CONCLUSIONS

Our study confirms an enduring shift towards a higher proportion of aggressive PCa at diagnosis, likely influenced by the COVID-19 pandemic. The impact of the 2018 USPSTF PCa screening recommendation on the proportion of aggressive PCa seems restricted and likely affected by the pandemic outbreak. Future investigations should evaluate the long-term effects of the 2018 USPSTF recommendations in the postpandemic setting.

The Risk of Catastrophic Healthcare Expenditures Among Prostate and Bladder Cancer Survivors in the United States

INTRODUCTION

Little is known about the rates of catastrophic health care expenditures among survivors of prostate and bladder cancer or the factors that place patients at highest risk for undue cost.

MATERIALS AND METHODS

The Medical Expenditure Panel Survey was utilized to identify prostate and bladder cancer survivors from 2011 to 2019. Rates of catastrophic health care expenditures (out-of-pocket health care spending >10% household income) were compared between cancer survivors and adults without cancer. A multivariable regression model was used to identify risk factors for catastrophic expenditures.

RESULTS

Among 2620 urologic cancer survivors, representative of 3,251,500 (95% CI 3,062,305-3,449,547) patients annually after application of survey weights, there were no significant differences in catastrophic expenditures among respondents with prostate cancer compared to adults without cancer. Respondents with bladder cancer had significantly greater rates of catastrophic expenditures (12.75%, 95% CI 9.36%-17.14% vs. 8.33%, 95% CI 7.66%-9.05%, P = .027). Significant predictors of catastrophic expenditures in bladder cancer survivors included older age, comorbidities, lower income, retirement, poor health status, and private insurance. Though White respondents with bladder cancer had no significantly increased risk of catastrophic expenditures, among Black respondents the risk of catastrophic expenditures increased from 5.14% (95% CI 3.95-6.33) without bladder cancer to 19.49% (95% CI 0.84-38.14) with bladder cancer (OR 6.41, 95% CI 1.28-32.01, P = .024).

CONCLUSIONS

Though limited by small sample size, these data suggest that bladder cancer survivorship is associated with catastrophic health care expenditures, particularly among Black cancer survivors. These findings should be taken as hypothesis-generating and warrant further investigation with larger sample sizes and, ideally, prospective investigation.

Impact of COVID-19 pandemic on ambulatory urologic oncology surgeries

INTRODUCTION

Robot-assisted laparoscopic prostatectomy (RALP) and transurethral resection of bladder tumor (TURBT) are two common surgeries for prostate and bladder cancer. We aim to assess the trends in the site of care for RALP and TURBT before and after the COVID outbreak.

MATERIALS AND METHODS

We identified adults who underwent RALP and TURBT within the California Healthcare Cost and Utilization Project State Inpatient Database and the State Ambulatory Surgery Database between 2018 and 2020. Multivariable analysis and spline analysis with a knot at COVID outbreak were performed to investigate the time trend and factors associated with ambulatory RALP and TURBT.

RESULTS

Among 17,386 RALPs, 6,774 (39.0%) were ambulatory. Among 25,070 TURBTs, 21,573 (86.0%) were ambulatory. Pre-COVID, 33.5% of RALP and 85.3% and TURBT were ambulatory, which increased to 53.8% and 88.0% post-COVID (both p < 0.001). In multivariable model, RALP and TURBT performed after outbreak in March 2020 were more likely ambulatory (OR 2.31, p < 0.0001; OR 1.25, p < 0.0001). There was an overall increasing trend in use of ambulatory RALP both pre- and post-COVID, with no significant change of trend at the time of outbreak (p = 0.642). TURBT exhibited an increased shift towards ambulatory sites post-COVID (p < 0.0001).

CONCLUSIONS

We found a shift towards ambulatory RALP and TURBT following COVID outbreak. There was a large increase in ambulatory RALP post-COVID, but the trend of change was not significantly different pre- and post-COVID - possibly due to a pre-existing trend towards ambulatory RALP which predated the pandemic.

Uncovering the Changing Treatment Landscape for Low-risk Prostate Cancer in the USA from 2010 to 2020: Insights from the National Cancer Data Base

The management of prostate cancer (PCa) has evolved from a paradigm of "treat when caught early" to "treat only when necessary". Despite inconsistency in its use, active surveillance has evolved over the past two decades into the gold standard for management of low-risk PCa. Our objective was to investigate whether the use of expectant management (active surveillance, watchful waiting, no treatment) as a first-line approach for low-risk PCa has increased over the past decade. We queried the US National Cancer Data Base for men diagnosed with localized PCa between 2010 and 2020. Two multivariable logistic regression models with different two-way interaction terms (year of diagnosis × D'Amico risk classification, and year of diagnosis × International Society of Urological Pathology [ISUP] grade group) were fitted to predict the probability of undergoing expectant management versus active treatment. The predicted probability of expectant management increased from 13.7% in 2010 to 64.4% in 2020 for men with low-risk PCa, and from 12.9% in 2010 to 61.6% in 2020 for ISUP grade group 1 PCa (both pinteraction < 0.001). The frequency of expectant management for low-risk PCa has increased dramatically during the past decade. We expect this trend to further increase owing to the growing awareness of the harms of overtreatment of indolent disease. PATIENT SUMMARY: We examined the use of expectant management for prostate cancer between 2010 and 2020 in a large hospital-based registry from the USA. We found that the proportion of men receiving expectant management for low-risk prostate cancer is increasing. We conclude that growing awareness of the harms of overtreatment has profoundly affected trends for prostate cancer treatment in the USA.

Outcomes for Arthroplasties in Military Health: A Retrospective Analysis of Direct Versus Purchased Care

INTRODUCTION

The Department of Defense is reforming the military health system where surgeries are increasingly referred from military treatment facilities (MTFs) with direct care to higher-volume civilian hospitals under purchased care. This shift may have implications on the quality and cost of care for TRICARE beneficiaries. This study examined the impact of care source and surgical volume on perioperative outcomes and cost of total hip arthroplasties (THAs) and total knee arthroplasties (TKAs).

MATERIALS AND METHODS

We examined TRICARE claims for patients who underwent THA or TKA between 2006 and 2019. The 30-day readmissions, complications, and costs between direct and purchased care were evaluated using the logistic regression model for surgical outcomes and generalized linear models for cost.

RESULTS

We included 71,785 TKA and THA procedures. 11,013 (15.3%) were performed in direct care. They had higher odds of readmissions (odds ratio, OR 1.29 [95% CI, 1.12-1.50]; P < 0.001) but fewer complications (OR 0.83 [95% CI, 0.75-0.93]; P = 0.002). Within direct care, lower-volume facilities had more complications (OR 1.27 [95% CI, 1.01-1.61]; P = 0.05). Costs for index surgeries were significantly higher at MTFs $26,022 (95% CI, $23,393-$28,948) vs. $20,207 ($19,339-$21,113). Simulating transfer of care to very high-volume MTFs, estimated cost savings were $4,370/patient and $20,229,819 (95% CI, $17,406,971-$25,713,571) in total.

CONCLUSIONS

This study found that MTFs are associated with lower odds of complications, higher odds of readmission, and higher costs for THA and TKA compared to purchased care facilities. These findings mean that care in the direct setting is adequate and consolidating care at higher-volume MTFs may reduce health care costs.

Association of Urinary Incontinence and Depression: Findings From the National Health and Nutrition Examination Survey

OBJECTIVE

To evaluate the association between urinary incontinence and depression. An estimated 21 million adults in the United States (U.S.) reported at least one major depressive episode. Urinary incontinence has a well-described negative impact on quality of life.

METHODS

We included respondents aged ≥20 who participated in the 2017 - March 2020 National Health and Nutrition Examination Survey cycles. Our dichotomous outcomes were depression and clinical depression. The predictor variable urinary incontinence was assessed using the validated incontinence severity index. We fitted an adjusted multivariable logistic regression and performed interaction analysis for urinary incontinence and our variable of interest.

RESULTS

Among a weighted sample of 233.5 million people (unweighted 8256), 19.9 million (8.5%) reported depression (P < .001). The weighted population was 48.6% male, 55.2% married, and 63.4% non-Hispanic White (all P < .001). Moderate and severe urinary incontinence was associated with depression (adjusted odds ratio [aOR] 2.3; 95%CI [1.5-3.3]; aOR 3.8; 95%CI [2.5-3.3]; P < .001). No association was observed between urinary incontinence and clinical depression. Interaction analysis showed that men (aOR 3.62; 95%CI [2.13-6.15]; Pint<.001) and participants at the lowest socioeconomic status (aOR 2.2; 95%CI [1.3-3.71]; Pint=.005) with moderate/severe urinary incontinence had higher odds of depression than their continent counterparts.

CONCLUSION

We report that urinary incontinence is an independent predictor of depression in a nationally representative survey for men and those in the lowest socioeconomic tier. The association is most prominent among men and the socioeconomically disadvantaged population. This suggests that treatment for urinary incontinence may be important tool to reduce depression in the general population.

Trends in Prostate Cancer Screening in the Pre- and Peri-COVID-19 Pandemic Period

INTRODUCTION

This study sought to examine PSA testing rates before, early in, and later in the COVID-19 pandemic.

METHODS

Our cohort included test results from men >45 years who received PSA testing at least once at our institution from November 2018 to September 2021 and were alive at the end of that period. Monthly trends were evaluated for 3 periods: pre-COVID (November 2018-February 2020), early-COVID (March-May 2020), and late-COVID (June 2020-September 2021). Univariable and multivariable analysis tested the impact of these periods on PSA testing rate, after accounting for available confounders. All analyses were stratified by prostate cancer diagnosis status.

RESULTS

A total of 141,777 PSA tests met inclusion criteria. The monthly number of tests in men without prostate cancer declined from 3,669 pre-COVID to 1,760 early-COVID (52% decrease; P = .0086) before increasing to 4,171 (14% increase from pre-COVID; P < .0001) late-COVID. The monthly average of first-time tests declined from 805 pre-COVID to 315 early-COVID (61% decrease; P = .008) before rebounding to 795 (1% decrease from pre-COVID; P = .7) late-COVID. The monthly number of tests in prostate cancer patients declined from 343 pre-COVID to 195 early-COVID (43% decrease; P = .008) before partially rebounding to 313 (9% decrease; P = .03) late-COVID. These differences remained within multivariable models.

CONCLUSIONS

A number of men have forgone first-time PSA testing opportunities following the COVID-19 outbreak; thus, early cancer diagnoses in some individuals might have been missed. Likewise, many prostate cancer patients have forgone follow-up in the late-COVID period, which might compromise their oncologic outcomes.

The national utilization of nonoperative management for small renal masses over 10 years

BACKGROUND

Management of small renal masses often involves a nonoperative approach, but there is a paucity of information about the use and associated predictors of such approaches. This study aimed to determine the trends in and predictors of use of nonoperative management of small renal masses.

METHODS

Using data from the National Cancer Database for localized small renal masses (N0/M0, cT1a) diagnosed between 2010 and 2020, we conducted a cross-sectional study. Nonoperative management was defined as expectant management (active surveillance or watchful waiting) or focal ablation. Adjusted odds ratios (AORs) were calculated using multivariable logistic regression models.

RESULTS

Of the 156 734 patients included, 10.5% underwent expectant management, and 13.9% underwent focal ablation. Later year of diagnosis was associated with a higher likelihood of nonoperative management. In 2020, the odds of receiving expectant management and focal ablation were 90% (AOR = 1.90, 95% confidence interval [CI] = 1.71 to 2.11) and 44% (AOR = 1.44, 95% CI = 1.31 to 1.57) higher, respectively, than in 2010. Black patients had increased odds of expectant management (AOR = 1.47, 95% CI = 1.39 to 1.55) but decreased odds of focal ablation (AOR = 0.93, 95% CI = 0.88 to 0.99).

CONCLUSION

Over the decade, the use nonoperative management of small renal masses increased, with expectant management more frequently used than focal ablation among Black patients. Possible explanations include race-based differences in physicians' risk assessments and resource allocation. Adjusting for Black race in calculations for glomerular filtration rate could influence the differential uptake of these techniques through deflated glomerular filtration rate calculations. These findings highlight the need for research and policies to ensure equitable use of less invasive treatments in small renal masses.

Changes in anxiety and depression in patients with different income levels through the COVID-19 pandemic

BACKGROUND

Lower socioeconomic status is known to be associated with high mental health burden, there have been few epidemiological studies showing how socioeconomic status has modified the effect of COVID-19 on anxiety and depression.

METHODS

We analyzed data from the National Health Interview Survey in the United States between 2019 and 2021 and used respondents with a documented income-to-poverty ratio as a measure of income level (n = 79,468). We used frequency of medication use and self-reported frequency of anxious and depressive episodes as the main outcome measures. We performed a multivariable logistic regression with a two-way interaction term between income and survey year.

RESULTS

We found a statistically significant worsening of depression and anxiety metrics in respondents with higher income levels from 2019 to 2021. We did not observe a significant change in anxiety and depression metrics for low-income respondents over the same period.

LIMITATIONS

The data from the NHIS survey is limited primarily by sampling bias (response rate of 50.7 % in 2021), as well as the self-reported nature of the one of the outcome measures.

CONCLUSION

These findings suggest that, within the limits of the National Health Interview Survey, mental health outcomes were worse but stable in a socioeconomically disadvantaged demographic between 2019 and 2021. In a higher socioeconomic bracket, mental health outcomes were less severe than the disadvantaged demographic but were worsening at a greater rate.

Indications for Adjuvant Radiation after Radical Prostatectomy as Predicted by Artificial Intelligence-Derived Dominant Intraprostatic Lesion Volume

PURPOSE/OBJECTIVE(S)

In prostate cancer, PI-RADs scores of dominant intraprostatic lesions (DILs) in multi-parametric magnetic resonance imaging (mpMRI) are prognostic; however, their inter-observer agreement is only moderate. Artificial intelligence (AI) may be a powerful tool for prognostication by analyzing a large number of scans consistently in a short amount of time. This study investigated whether the DIL volume (DILvol) provided by an AI deep-learning segmentation algorithm could predict adverse findings at radical prostatectomy (RP), some of which could warrant adjuvant radiation therapy (RT).

MATERIALS/METHODS

We conducted a retrospective study of 185 consecutive patients with localized prostate cancer who underwent an endorectal coil, high B-value (> = 1000 s/mm2), 3-Tesla mpMRI followed by RP between 2015 and 2017. Using a previously trained deep learning nnUNet algorithm for providing DIL segmentations from patients treated with definitive RT, we segmented the DIL for the RP cohort. We evaluated the association of AI DILvol with the risks of adverse pathologic factors, including positive margins, pathologic T3 (pT3) disease, and pathologic Gleason (pGS8-10) disease, using separate univariate logistic regression models. We then included AI DILvol, pT3 (vs pT2), pGS8-10 (vs pGS6-7), margin status, and pre-RP PSA for predicting post-RP PSA values utilizing multivariate linear regression analysis. Finally, we included these same factors into a multivariate logistic regression analysis for predicting the risk of meeting adjuvant RT indications (PSA persistence post-RP > = 0.1 ng/mL or positive lymph nodes).

RESULTS

The median time between RP and post-PSA value was 1.6 months. The Pearson's correlation coefficient between AI and reference DILvol (sum of manually contoured PI-RADS 3-5 lesions) was 0.86 (p < 0.001). The Pearson's correlation coefficient between AI DILvol and pathologic tumor size was 0.63 (p < 0.001). Utilizing separate univariate logistic regression models, we found that AI DILvol was significantly associated with the risks of positive margins (OR 1.31 [1.10, 1.58]; p = 0.003), pT3 (OR 1.59 [95% CI: 1.30, 1.99]; p < 0.001), and pGS8-10 (OR 1.28 [1.07, 1.56]; p = 0.01). On multivariate linear regression, AI DILvol (0.27/mL [0.25, 0.29]; p < 0.001) was significantly correlated with post-RP PSA values, after controlling for adverse factors and pre-RP PSA. On multivariate logistic regression, AI DILvol (adjusted OR 1.32 [1.05, 1.69]; p = 0.03) was the only factor significantly associated with the risk of meeting adjuvant RT indications after controlling for these same factors.

CONCLUSION

For localized prostate cancer treated with RP, AI DILvol was the only factor significantly associated with the risk of meeting adjuvant RT indications, even after controlling for pathologic factors at RP. Further studies are needed to determine if AI DILvol is prognostic for long-term oncologic outcomes after RP.

Venture capital investment in urology, 2011 to mid-2021

INTRODUCTION

To characterize venture capital (VC) investments in urology in the past decade that represent promising innovations in early-stage companies.

MATERIALS AND METHODS

A retrospective analysis of deals made between VC investors and urologic companies from January 1, 2011, through June 28, 2021, was conducted by using a financial database (PitchBook Platform, PitchBook Data Inc). Data on urologic company and investor names; company information and funding categories (surgical device, therapeutic device, drug discovery/pharmaceutical, and health care technology companies); and deal sizes (in US dollars) and dates were abstracted and aggregated. Descriptive and linear regression analyses were conducted.

RESULTS

Urology-related VC funding fluctuated from 2011 through mid-2021, but no substantial change was observed in funding over time. In total, 191 distinct deals were made involving urologic companies, totaling $1.1 billion. The four largest funding categories together accounted for $848 million and comprised therapeutic devices ($373 million), surgical devices ($187 million), drug discovery/pharmaceuticals ($185 million), and health care technology ($102 million). At least $450 million (41% of total investments) was invested in companies developing minimally invasive surgical devices.

CONCLUSIONS

Urologic VC investments did not increase in the past decade and were allocated more toward devices than pharmaceuticals or health care technology. Given relative patterns within urology, VC investments may shift toward health care technology and away from pharmaceuticals but remain stable for devices. Further investments in promising technologies may help urologists more effectively manage urologic disease while optimizing outcomes.

Conditional survival does not improve over time in metastatic castration-resistant prostate cancer patients undergoing docetaxel

PURPOSE

To investigate the conditional overall survival (OS) of metastatic castration-resistant prostate cancer (mCRPC) patients receiving docetaxel chemotherapy.

METHODS

We used deidentified patient-level data from the Prostate Cancer DREAM Challenge database and the control arm of the ENTHUSE 14 trial. We identified 2158 chemonaïve mCRPC patients undergoing docetaxel chemotherapy in the five randomized clinical trials. The 6-month conditional OS was calculated at times 0, 6, 12, 18, and 24 months from randomization. Survival curves of each group were compared using the log-rank test. Patients were then stratified into low- and high-risk groups based on the median predicted value of our recently published nomogram predicting OS in mCRPC patients.

RESULTS

Nearly half (45%) of the study population was aged between 65 and 74 years. Median interquartile range prostate-specific antigen for the overall cohort was 83.2 (29.6-243) ng/mL, and 59% of patients had bone metastasis with or without lymph node involvement. The 6-month conditional survival rates at 0, 6, 12, 18, and 24 months for the entire cohort were 93% (95% confidence interval [CI]: 92-94), 82% (95% CI: 81-84), 76% (95% CI: 73-78), 75% (95% CI: 71-78), and 71% (95% CI: 65-76). These rates were, respectively, 96% (95% CI: 95-97), 92% (95% CI: 90-93), 84% (95% CI: 81-87), 81% (95% CI: 77-85), and 79% (95% CI: 72-84) in the low-risk group and 89% (95% CI: 87-91), 73% (95% CI: 70-76), 65% (95% CI: 60-69), 64% (95% CI: 58-70), and 58% (95% CI: 47-67) in the high-risk group.

CONCLUSION

The conditional OS for patients undergoing docetaxel chemotherapy tends to plateau over time, with the main drop in conditional OS happening during the first year from initiating docetaxel treatment. That is the longer a patient survives, the more likely they are to survive further. This prognostic information could be a useful tool for a more accurate tailoring of both follow-up and therapies.

PATIENT SUMMARY

In this report, we looked at the future survival in months of patients with metastatic castration resistant prostate cancer on chemotherapy who have already survived a certain period. We found that the longer time that a patient survives, the more likely they will continue to survive. We conclude that this information will help physicians tailor follow-ups and treatments for patients for a more accurate personalized medicine.

Predictors of Financial Toxicity Among United States Prostate Cancer Survivors: Results From a National Survey

INTRODUCTION

Despite increasing attention to financial toxicity associated with prostate cancer, national rates of subjective and objective financial toxicity have not been well characterized, and it remains unknown which prostate cancer survivors are at highest risk for undue financial burden.

METHODS

Men with a history of prostate cancer were identified from the Medical Expenditure Panel Survey. The proportion of men reporting catastrophic health care expenditures (out-of-pocket spending >10% of income) and other measures of financial toxicity were assessed. Multivariable logistic regression was used to identify independent predictors of financial toxicity.

RESULTS

Of a weighted estimate of 2,349,532 men with a history of prostate cancer, 13.5% reported catastrophic health care expenditures, 16% reported subjective worry about ability to pay medical bills, and 15% reported work changes due to their cancer diagnosis. Significant predictors of catastrophic expenditures included private insurance (OR 4.62, 95% CI 1.29-16.49) and medical comorbidities (OR 1.38, 95% CI 1.05-1.82), while high income was protective (>400% vs <100% federal poverty level, OR 0.06, 95% CI 0.02-0.19). Each year of older age was associated with decreased odds of subjective worry about medical bills. Only 12% of men reported their doctor discussed the costs of care in detail.

CONCLUSIONS

Nearly 1 in 7 prostate cancer survivors experience catastrophic health care expenditures, and a larger proportion report subjective manifestations of financial toxicity. Many men report their physicians did not address the financial side effects of treatment. These results highlight the patient characteristics associated with this important side effect of prostate cancer care.

Drug-induced acute pancreatitis due to medications used for inflammatory bowel disease: A VigiBase pharmacovigilance database study

BACKGROUND

Nearly all medications used for inflammatory bowel disease (IBD) have been reported as causes of acute pancreatitis (AP), with the thiopurines being among the most frequently described. However, with the development of newer medications, thiopurine monotherapy has largely been replaced by newer immunosuppressive drugs. There are few data on the association between AP and biologic/small molecule agents.

METHODS

VigiBase, the World Health Organization's Global Individual Case Safety Report database, was used to assess the association between AP and common IBD medications. A case/non-case disproportionality analysis was performed and disproportionality signals were reported as a reporting odds ratio (ROR) with 95% confidence intervals (CIs).

RESULTS

A total of 4,223 AP episodes were identified for common IBD medications. Azathioprine (ROR 19.18, 95% CI 18.21-20.20), 6-mercaptopurine (ROR 13.30, 95% CI 11.73-15.07), and 5-aminosalicylic acid (ROR 17.44, 95% CI 16.24-18.72) all had strong associations with AP, while the biologic/small molecule agents showed weaker or no disproportionality. The association with AP was much higher for thiopurines when used for Crohn's disease (ROR 34.61, 95% CI 30.95-38.70) compared to ulcerative colitis (ROR 8.94, 95% CI 7.47-10.71) or rheumatologic conditions (ROR 18.87, 95% CI 14.72-24.19).

CONCLUSIONS

We report the largest real-world database study investigating the association between common IBD medications and AP. Among commonly used IBD medications including biologic/small molecule agents, only thiopurines and 5-aminosalicylic acid are strongly associated with AP. The association between thiopurines and AP is much stronger when the drug is used for Crohn's disease compared to ulcerative colitis and rheumatologic conditions.

Disparities in Travel-Related Barriers to Accessing Health Care From the 2017 National Household Travel Survey

Importance

Geographic access, including mode of transportation, to health care facilities remains understudied.

Objective

To identify sociodemographic factors associated with public vs private transportation use to access health care and identify the respondent, trip, and community factors associated with longer distance and time traveled for health care visits.

Design, Setting, and Participants

This cross-sectional study used data from the 2017 National Household Travel Survey, including 16 760 trips or a nationally weighted estimate of 5 550 527 364 trips to seek care in the United States. Households that completed the recruitment and retrieval survey for all members aged 5 years and older were included. Data were analyzed between June and August 2022.

Exposures

Mode of transportation (private vs public transportation) used to seek care.

Main Outcomes and Measures

Survey-weighted multivariable logistic regression models were used to identify factors associated with public vs private transportation and self-reported distance and travel time. Then, for each income category, an interaction term of race and ethnicity with type of transportation was used to estimate the specific increase in travel burden associated with using public transportation compared a private vehicle for each race category.

Results

The sample included 12 092 households and 15 063 respondents (8500 respondents [56.4%] aged 51-75 years; 8930 [59.3%] females) who had trips for medical care, of whom 1028 respondents (6.9%) were Hispanic, 1164 respondents (7.8%) were non-Hispanic Black, and 11 957 respondents (79.7%) were non-Hispanic White. Factors associated with public transportation use included non-Hispanic Black race (compared with non-Hispanic White: adjusted odds ratio [aOR], 3.54 [95% CI, 1.90-6.61]; P < .001) and household income less than $25 000 (compared with ≥$100 000: aOR, 7.16 [95% CI, 3.50-14.68]; P < .001). The additional travel time associated with use of public transportation compared with private vehicle use varied by race and household income, with non-Hispanic Black respondents with income of $25 000 to $49 999 experiencing higher burden associated with public transportation (mean difference, 81.9 [95% CI, 48.5-115.3] minutes) than non-Hispanic White respondents with similar income (mean difference, 25.5 [95% CI, 17.5-33.5] minutes; P < .001).

Conclusions and Relevance

These findings suggest that certain racial, ethnic, and socioeconomically disadvantaged populations rely on public transportation to seek health care and that reducing delays associated with public transportation could improve care for these patients.

MRI-Targeted, Systematic, or Combined Biopsy for Detecting Clinically Significant Prostate Cancer

PURPOSE

The aim of this study was to assess MRI-targeted, systematic, or combined prostate biopsy for diagnosing prostate cancer to identify opportunities for diagnostic accuracy improvement.

METHODS

This institutional review board-approved, retrospective study, performed at a large, quaternary hospital, included all men undergoing prostate multiparametric MRI (mpMRI) from January 1, 2015, to December 31, 2019, with prostate-specific antigen ≥ 4 ng/mL, biopsy target on mpMRI (Prostate Imaging Reporting and Data System [PI-RADS] 3-5 lesion), and combined targeted and systematic biopsy ≤6 months after MRI. Analysis included the highest grade lesion per patient. The primary outcome was prostate cancer diagnosis by grade group (GG; 1, 2, and ≥3). Secondary outcomes were rates of cancer upgrading by biopsy type and cancer proximity to the targeted biopsy site in patients upgraded by systematic biopsy.

RESULTS

Two hundred sixty-seven biopsies (267 patients) were included; 94.4% (252 of 267) were biopsy naive. The most suspicious mpMRI lesion was PI-RADS 3 in 18.7% (50 of 267), PI-RADS 4 in 52.4% (140 of 267), and PI-RADS 5 in 28.8% (77 of 267). Prostate cancer was diagnosed in 68.5% (183 of 267): 22.1% (59 of 267) GG 1, 16.1% (43 of 267) GG 2, and 30.3% (81 of 267) GG ≥ 3. Combined biopsy (124 of 267) yielded more GG ≥ 2 prostate cancer diagnoses than systematic (87 of 267) or targeted (110 of 267) biopsy alone. More GG ≥ 2 cancers were upgraded by targeted biopsy than by systematic biopsy (P = .0062). Systematic biopsy upgrades were in close proximity to the targeted biopsy site in 42.1% (24 of 57); GG ≥ 3 cancers 62.5% (15 of 24) constituted most proximal misses.

CONCLUSIONS

In men with prostate-specific antigen ≥ 4 ng/mL and PI-RADS 3, 4, or 5 lesion on mpMRI, combined biopsy led to more prostate cancer diagnoses than targeted or systematic biopsy alone. Cancers upgraded by systematic biopsy proximal and distant from the targeted biopsy site may indicate opportunities for biopsy and mpMRI improvement, respectively.