PSA screening, prostate biopsy, and treatment of prostate cancer in the years surrounding the USPSTF recommendation against prostate cancer screening

BACKGROUND

The 2012 United States Preventive Services Task Force recommendation against screening for prostate cancer has impacted rates of prostate-specific antigen (PSA) screening and appears to be associated with declining prostate cancer incidence. Our objective was to characterize health care utilization that may explain these observed trends.

METHODS

MarketScan claims, which capture >30 million privately insured patients in the United States, were queried for all men aged 40-64 years for the years 2008-2014. PSA testing, prostate biopsy, prostate cancer diagnosis, and definitive local treatment were determined using associated International Classification of Diseases, Ninth Revision and Current Procedural Terminology, Fourth Edition codes.

RESULTS

There were approximately 6 million qualifying men with a full year of data. PSA testing, prostate biopsy, and prostate cancer detection declined significantly between 2009 and 2014, most notably after 2011. The prostate biopsy rate per 100 patients with a PSA test decreased over the study period from 1.95 (95% confidence interval [CI], 1.92-1.97) to 1.52 (95% CI, 1.50-1.54). Prostate cancer incidence per prostate biopsy increased over the study period from 0.36 (95% CI, 0.35-0.36) to 0.39 (95% CI, 0.39-0.40). Of new prostate cancer diagnoses, the proportion managed with definitive local treatment decreased from 69% (95% CI, 69%-70%) to 54% (95% CI, 53%-55%). Both PSA testing and prostate cancer incidence decreased significantly after 2011 (P < .001).

CONCLUSION

In a large cohort of privately insured men, PSA testing, prostate biopsy, prostate cancer incidence, and local definitive treatment for prostate cancer decreased between 2008 and 2014, most notably after 2011. This decrease may be driven by differential referral patterns from primary care providers to urologists. Cancer 2018;124:2733-2739. © 2018 American Cancer Society.

National Imaging Trends after Percutaneous Nephrolithotomy

PURPOSE

Followup imaging after percutaneous nephrolithotomy serves to detect postoperative complications, residual fragments and silent hydronephrosis. However, the timing and optimal imaging modality remain poorly defined. We describe imaging use patterns after percutaneous nephrolithotomy.

MATERIALS AND METHODS

In the MarketScan® database we identified patients 17 to 64 years old who underwent percutaneous nephrolithotomy between 2007 and 2014. Imaging modalities were identified by CPT, and ICD-9 and 10 codes, and tracked for 1 year after percutaneous nephrolithotomy. The modalities included computerized tomography, renal ultrasound, abdominal x-ray and intravenous pyelogram. Cumulative longitudinal use patterns were characterized and the association with demographic factors was assessed by the chi-square test.

RESULTS

Of the 6,495 patients included in analysis 29% and 15% had undergone no postoperative imaging by 3 and 12 months, respectively. While abdominal x-ray was the most common modality at 3, 6 and 12 months, performed in 46%, 53% and 62% patients, respectively, nearly 50% underwent computerized tomography by 1 year. Of these patients 34% underwent computerized tomography within 3 months, which was done within the first 3 days in 69%. During the study period renal ultrasound use increased by 13% while computerized tomography and abdominal x-ray use remained relatively stable. Female gender, residence in the Northeast, no health maintenance organization status and treatment in a metropolitan statistical area were independently associated with higher rates of renal ultrasound on multivariate analyses (p <0.05).

CONCLUSIONS

Among insured adults national imaging patterns vary following percutaneous nephrolithotomy. Many patients do not receive any followup imaging while approximately half undergo computerized tomography within a year. Imaging patterns may be evolving with the increased use of ultrasound.

National Imaging Trends after Ureteroscopic or Shock Wave Lithotripsy for Nephrolithiasis

PURPOSE

The study of diagnostic imaging after procedural intervention for nephrolithiasis is limited. We sought to characterize actual national imaging patterns and longitudinal trends after ureteroscopic or shock wave lithotripsy.

MATERIALS AND METHODS

We analyzed the MarketScan® database and identified a nationally representative sample of insured, employed patients, 17 to 64 years old who underwent ureteroscopic or shock wave lithotripsy for nephrolithiasis between 2007 and 2014. Patients were excluded from study if they lacked at least 1 year of postoperative database enrollment or underwent a repeat nephrolithiasis procedure of any type within 90 days after the initial procedure. We identified and tracked postoperative imaging modalities by medical billing codes.

RESULTS

We identified 101,554 patients treated with ureteroscopy, of whom 55% and 39% underwent no postoperative imaging within 3 and 12 months, respectively. Of the 101,590 patients treated with shock wave lithotripsy 23% and 16% underwent no postoperative imaging within 3 and 12 months, respectively. Abdominal x-ray was the most common imaging modality after either procedure type. Ultrasound use increased with time while computerized tomography decreased. In about 25% of ureteroscopy and shock wave lithotripsy cases at least 1 postoperative computerized tomography was done within a year. Female gender and older age were associated with higher imaging rates. Ultrasound was more commonly performed in the northeast region and in more densely populated areas.

CONCLUSIONS

A notable portion of patients treated with ureteroscopy and a smaller percent treated with shock wave lithotripsy do not undergo any followup imaging within 1 year. In the majority who undergo imaging abdominal x-ray is done, precluding the ability to screen for hydronephrosis or silent obstruction in almost 75% of patients treated with ureteroscopy.

Longitudinal Patterns of Occurrence and Remission of Erectile Dysfunction in Men With Type 1 Diabetes

BACKGROUND

Men with diabetes are at greater risk of erectile dysfunction (ED).

AIM

To describe the natural history of ED in men with type 1 diabetes.

METHODS

We examined up to 30 years of prospectively collected annual ED status and demographic and clinical variables from 600 male participants in the Diabetes Control and Complications Trial (DCCT; 1983-1993) and its follow-up study, the Epidemiology of Diabetes Interventions and Complications (1994-present; data in this study are through 2012).

OUTCOMES

Yes vs no response to whether the participant had experienced impotence in the past year and whether he had used ED medication.

RESULTS

Sixty-one percent of men reported ED at least once during the study. For some men, the initial report of ED was permanent. For others, potency returned and was lost multiple times. Visual display of the data showed four longitudinal ED phenotypes: never (38.7%), isolated (6.7%), intermittent (41.8%), and persistent (12.8%). Men who never reported ED or in only 1 isolated year were younger, had lower body mass index, and better glycemic control than men in the intermittent and persistent groups at DCCT baseline. In a multivariable logistic model comparing men at their first year reporting ED, men who were older had lower odds of remission and men who were in the conventional DCCT treatment group had higher odds of remission.

CLINICAL TRANSLATION

If validated in other cohorts, such findings could be used to guide individualized interventions for patients with ED.

STRENGTHS AND LIMITATIONS

This is the first examination of ED with repeated measures at an annual resolution, with up to 30 years of responses for each participant. However, the yes vs no response is a limitation because the real phenotype is not binary and the question can be interpreted differently depending on the participant.

CONCLUSIONS

Age, glycemic control, and BMI were important longitudinal predictors of ED. We have described a more complex ED phenotype, with variation in remission patterns, which could offer insight into different mechanisms or opportunities for intervention. If validated in other cohorts, such findings could be used to establish more accurate prognostication of outcomes for patients with ED to guide individualized interventions. Palmer MR, Holt SK, Sarma AV, et al. Longitudinal Patterns of Occurrence and Remission of Erectile Dysfunction in Men With Type 1 Diabetes. J Sex Med 2017;14:1187-1194.

Variable Resource Utilization in the Prenatal and Postnatal Management of Isolated Hydronephrosis

OBJECTIVE

To characterize contemporary resource utilization and medical outcomes for infants with antenatal hydronephrosis and their mothers from a national claims database. We hypothesize that management of isolated hydronephrosis (IHN) varies widely, with decreased imaging following the 2010 Society for Fetal Urology Consensus Statement.

MATERIALS AND METHODS

Using MarketScan claims from 2007 to 2013, we identified infants 0-12 months of age with hydronephrosis and linked mothers. Those with urologic diagnoses more specific than hydronephrosis, additional urologic comorbidities, or postnatal surgeries were excluded. Resource utilization including prenatal and postnatal imaging, laboratory studies, hospital admissions, and medical outcomes within the first year was captured. Demographics, maternal characteristics, utilization measures, and outcomes were compared across imaging intensity groups based on number of postnatal ultrasounds received using bivariate analysis.

RESULTS

Among 801,919 mother-child pairs, 8610 infants (1.1%) had hydronephrosis or a related diagnosis. A total of 5876 (68.2%) met inclusion criteria for IHN. Patients underwent a mean 5.3 ± 3.5 prenatal and 2.1 ± 1.3 postnatal ultrasounds before age 1. Imaging practices were unchanged following the Society for Fetal Urology consensus statement.

CONCLUSION

Antenatal hydronephrosis prevalence in an insured population is consistent with published ranges. Prenatal imaging in IHN is variable and potentially excessive. Future study into the efficacy of evidence-based pathways in reducing excess utilization is warranted.

Transgender-Related Education in Plastic Surgery and Urology Residency Programs

BACKGROUND

With increasing public awareness of and greater coverage for gender-confirming surgery by insurers, more transgender patients are likely to seek surgical transition. The degree to which plastic surgery and urology trainees are prepared to treat transgender patients is unknown.

OBJECTIVE

We assessed the number of hours dedicated to transgender-oriented education in plastic surgery and urology residencies, and the impact of program director (PD) attitudes on provision of such training.

METHODS

PDs of all Accreditation Council for Graduate Medical Education-accredited plastic surgery (91) and urology (128) programs were invited to participate. Surveys were completed between November 2015 and March 2016; responses were collected and analyzed.

RESULTS

In total, 154 PDs (70%) responded, and 145 (66%) completed the survey, reporting a yearly median of 1 didactic hour and 2 clinical hours of transgender content. Eighteen percent (13 of 71) of plastic surgery and 42% (31 of 74) of urology programs offered no didactic education, and 34% (24 of 71) and 30% (22 of 74) provided no clinical exposure, respectively. PDs of programs located in the southern United States were more likely to rate transgender education as unimportant or neutral (23 of 37 [62%] versus 39 of 105 [37%]; P = .017). PDs who rated transgender education as important provided more hours of didactic content (median, 1 versus 0.75 hours; P = .001) and clinical content (median, 5 versus 0 hours; P < .001).

CONCLUSIONS

A substantial proportion of plastic surgery and urology residencies provide no education on transgender health topics, and those that do, provide variable content. PD attitudes toward transgender-specific education appear to influence provision of training.

Characterization of an Abiraterone Ultraresponsive Phenotype in Castration-Resistant Prostate Cancer Patient-Derived Xenografts

Purpose: To identify the molecular signature associated with abiraterone acetate (AA) response and mechanisms underlying AA resistance in castration-resistant prostate cancer patient-derived xenografts (PDXs).Experimental Design: SCID mice bearing LuCaP 136CR, 77CR, 96CR, and 35CR PDXs were treated with AA. Tumor volume and prostate-specific antigen were monitored, and tumors were harvested 7 days after treatment or at end of study for gene expression and immunohistochemical studies.Results: Three phenotypic groups were observed based on AA response. An ultraresponsive phenotype was identified in LuCaP 136CR with significant inhibition of tumor progression and increased survival, intermediate responders LuCaP 77CR and LuCaP 96CR with a modest tumor inhibition and survival benefit, and LuCaP 35CR with minimal tumor inhibition and no survival benefit upon AA treatment. We identified a molecular signature of secreted proteins associated with the AA ultraresponsive phenotype. Upon resistance, AA ultraresponder LuCaP 136CR displayed reduced androgen receptor (AR) signaling and sustainably low nuclear glucocorticoid receptor (nGR) localization, accompanied by steroid metabolism alteration and epithelial-mesenchymal transition phenotype enrichment with increased expression of NF-κB-regulated genes; intermediate and minimal responders maintained sustained AR signaling and increased tumoral nGR localization.Conclusions: We identified a molecular signature of secreted proteins associated with AA ultraresponsiveness and sustained AR/GR signaling upon AA resistance in intermediate or minimal responders. These data will inform development of noninvasive biomarkers predicting AA response and suggest that further inhibition along the AR/GR signaling axis may be effective only in AA-resistant patients who are intermediate or minimal responders. These findings require verification in prospective clinical trials. Clin Cancer Res; 23(9); 2301-12. ©2016 AACR.

Preoperative Belladonna and Opium Suppository for Ureteral Stent Pain: A Randomized, Double-blinded, Placebo-controlled Study

OBJECTIVE

To investigate whether the use of a belladonna and opium (B&O) rectal suppository administered immediately before ureteroscopy (URS) and stent placement could reduce stent-related discomfort.

METHODS

A randomized, double-blinded, placebo-controlled study was performed from August 2013 to December 2014. Seventy-one subjects were enrolled and randomized to receive a B&O (15 mg/30 mg) or a placebo suppository after induction of general anesthesia immediately before URS and stent placement. Baseline urinary symptoms were assessed using the American Urological Association Symptom Score (AUASS). The Ureteral Stent Symptom Questionnaire and AUASS were completed on postoperative days (POD) 1, 3, and after stent removal. Analgesic use intraoperatively, in the recovery unit, and at home was recorded.

RESULTS

Of the 71 subjects, 65 had treatment for ureteral (41%) and renal (61%) calculi, 4 for renal urothelial carcinoma, and 2 were excluded for no stent placed. By POD3, the B&O group reported a higher mean global quality of life (QOL) score (P = .04), a better mean quality of work score (P = .05), and less pain with urination (P = .03). The B&O group reported an improved AUASS QOL when comparing POD1 with post-stent removal (P = .04). There was no difference in analgesic use among groups (P = .67). There were no episodes of urinary retention. Age was associated with unplanned emergency visits (P <.00) and "high-pain" measure (P = .02) CONCLUSION: B&O suppository administered preoperatively improved QOL measures and reduced urinary-related pain after URS with stent. Younger age was associated with severe stent pain and unplanned hospital visits.

Extreme Gleason Upgrading From Biopsy to Radical Prostatectomy: A Population-based Analysis

OBJECTIVE

To examine the risk factors associated with the odds of extreme Gleason upgrading at radical prostatectomy (RP) (defined as a Gleason prognostic group score increase of ≥2), we utilized a large, population-based cancer registry.

MATERIALS AND METHODS

The Surveillance, Epidemiologic, and End Results database was queried (2010-2011) for all patients diagnosed with Gleason 3 + 3 or 3 + 4 on prostate needle biopsy. Available clinicopathologic factors and the odds of upgrading and extreme upgrading at RP were evaluated using multivariate logistic regression.

RESULTS

A total of 12,459 patients were identified, with a median age of 61 (interquartile range: 56-65) and a diagnostic prostate-specific antigen (PSA) of 5.5 ng/mL (interquartile range: 4.3-7.5). Upgrading was observed in 34% of men, including 44% of 7402 patients with Gleason 3 + 3 and 19% of 5057 patients with Gleason 3 + 4 disease. Age, clinical stage, diagnostic PSA, and % prostate needle biopsy cores positive were independently associated with odds of any upgrading at RP. In baseline Gleason 3 + 3 disease, extreme upgrading was observed in 6%, with increasing age, diagnostic PSA, and >50% core positivity associated with increased odds. In baseline Gleason 3 + 4 disease, extreme upgrading was observed in 4%, with diagnostic PSA and palpable disease remaining predictive. Positive surgical margins were significantly higher in patients with extreme upgrading at RP (P < .001).

CONCLUSION

Gleason upgrading at RP is common in this large population-based cohort, including extreme upgrading in a clinically significant portion.

Characterizing the Morbidity of Postchemotherapy Retroperitoneal Lymph Node Dissection for Testis Cancer in a National Cohort of Privately Insured Patients

OBJECTIVE

To characterize morbidity of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for testis cancer, we analyze a contemporary national database. PC-RPLND is the standard for residual radiographic masses ≥1 cm (nonseminoma) and positron emission tomography-avid masses ≥3 cm (seminoma). Morbidity for PC-RPLND is greater than primary RPLND, which may be mitigated by performing surgery at a high-volume cancer center.

METHODS

Current Procedural Terminology and International Classification of Diseases, Ninth Edition codes identified men with testis cancer undergoing PC- or primary RPLND in MarketScan (2007-2012). Multivariable logistic regression assessed factors associated with receiving adjunctive procedures (ie, nephrectomy, vascular reconstruction), prolonged hospitalization, and 90-day readmission. Geographic variables assessed regionalization of PC-RPLND.

RESULTS

Of 559 men with claims for PC- or primary RPLND (206, 37% PC-RPLND), 19% of PC-RPLND underwent adjunctive procedures (vs 1% among RPLND, P  <  .01). For PC-RPLND, the nephrectomy rate was 10% and the vascular reconstruction rate was 8%. On multivariable analysis, PC-RPLND was associated with undergoing adjunctive procedures (odds ratio 41.9; 95% confidence interval 11.7, 150) and prolonged hospitalization (odds ratio 3.75; 95% confidence interval 1.68, 8.42) compared to primary RPLND. PC-RPLND was not associated with 90-day readmission. Up to 29% of PC-RPLNDs are performed in centers, billing just a single case through MarketScan in the 6 years studied.

CONCLUSION

PC-RPLND is associated with adjunctive procedures and longer hospitalizations. Given the morbidity of PC-RPLND in this young patient population, efforts are needed to establish quality benchmarks for, reduce the morbidity of, and to accurately discriminate risk during patient discussions prior to this complex, specialized surgery.

National Trends in Secondary Procedures Following Pediatric Pyeloplasty

PURPOSE

Although reported success rates after pediatric pyeloplasty to correct ureteropelvic junction are high, failure may require intervention. We sought to characterize the incidence and timing of secondary procedures after pediatric pyeloplasty using a national employer based insurance database.

MATERIALS AND METHODS

Using the MarketScan® database we identified patients 0 to 18 years old who underwent pyeloplasty from 2007 to 2013 with greater than 3 months of postoperative enrollment. Secondary procedures following the index pyeloplasty were identified by CPT codes and classified as stent/drain, endoscopic, pyeloplasty, nephrectomy or transplant. The risk of undergoing a secondary procedure was ascertained using Cox proportional hazards models adjusting for demographic and clinical characteristics.

RESULTS

We identified 1,976 patients with a mean ± SD followup of 23.9 ± 19.8 months. Overall 226 children (11.4%) had undergone at least 1 post-pyeloplasty procedure. The first procedure was done within 1 year in 87.2% of patients with a mean postoperative interval of 5.9 ± 11.1 months. Stents/drains, endoscopic procedures and pyeloplasties were noted in 116 (5.9%), 34 (1.7%) and 71 patients (3.1%), respectively. Length of stay was associated with undergoing a secondary procedure. Compared with 2 days or less the HR of 3 to 5 and 6 days or greater was 1.65 and 3.94 (p = 0.001 and <0.001, respectively).

CONCLUSIONS

Following pediatric pyeloplasty 1 of 9 patients undergoes at least 1 secondary procedure with the majority performed within the first year. One of 11 patients undergoes intervention more extensive than placement of a single stent or drain, requiring management strategies that generally signify recurrent or persistent obstruction. Estimates of pyeloplasty success in this national data set are lower than in other published series.

Prostate Cancer Expression Profiles of Cytoplasmic ERβ1 and Nuclear ERβ2 are Associated with Poor Outcomes following Radical Prostatectomy

PURPOSE

Existing data regarding the expression of estrogen receptors (ERs) and prostate cancer outcomes have been limited. We evaluated the relationship of expression profiles of ERβ subtypes and the ER GPR30 (G-protein-coupled receptor-30) with patient factors at diagnosis and outcomes following radical prostatectomy.

MATERIALS AND METHODS

Tissue microarrays constructed using samples from 566 men with long-term clinical followup were analyzed by immunohistochemistry targeting ERβ1, ERβ2, ERβ5 and GPR30. An experienced pathologist scored receptor distribution and staining intensity. Tumor staining characteristics were evaluated for associations with patient characteristics, recurrence-free survival and prostate cancer specific mortality following radical prostatectomy.

RESULTS

Prostate cancer cells had unique receptor subtype staining patterns. ERβ1 demonstrated predominantly nuclear localization while ERβ2, ERβ5 and GPR30 were predominantly cytoplasmic. After controlling for patient factors intense cytoplasmic ERβ1 staining was independently associated with time to recurrence (HR 1.7, 95% CI 1.1-2.6, p = 0.01) and prostate cancer specific mortality (HR 6.6, 95% CI 1.8-24.9, p = 0.01). Intense nuclear ERβ2 staining was similarly independently associated with prostate cancer specific mortality (HR 3.9, 95% CI 1.1-13.4, p = 0.03). Patients with cytoplasmic ERβ1 and nuclear ERβ2 co-staining had significantly worse 15-year prostate cancer specific mortality than patients with expression of only cytoplasmic ERβ1, only nuclear ERβ2 and neither ER (16.4%, 4.3%, 0.0% and 2.0 %, respectively, p = 0.001).

CONCLUSIONS

Increased cytoplasmic ERβ1 and nuclear ERβ2 expression is associated with worse cancer specific outcomes following radical prostatectomy. These findings suggest that tumor ERβ1 and ERβ2 staining patterns provide prognostic information on patients treated with radical prostatectomy.

Patient-centered risk stratification of disposition outcomes following radical cystectomy

PURPOSE

Patient-centered care involves providing understandable information to facilitate individualized health decisions among patients. We sought to determine the effect of age and comorbidity status on clinically meaningful outcomes following radical cystectomy (RC), in an effort the help optimize patient selection and enhance discussions among those considering surgery.

MATERIALS AND METHODS

In a retrospective review, 6,460 patients were treated with RC for bladder cancer from the U.S. Premier Perspectives Database between 2007 and 2013. The influence of age and comorbidity count on the rates of inpatient mortality, prolonged length of stay (LOS), disposition to other than home and hospital readmission within the month of surgery or month after, were assessed. Comorbidity was calculated using the Elixhauser method. Prolonged LOS was defined as >10 days. Multivariable logistic regression models were used.

RESULTS

Following RC, 16% of patients were discharged to somewhere other than home, 37% had a prolonged LOS and 2% died during the index admission. Among those discharged home after surgery, 27% of patients were readmitted. Prolonged LOS was associated with increasing comorbidities and age >70 years (P < 0.001). The adjusted likelihood of readmission increased with increasing burden of comorbid conditions (P < 0.001), however, not with age. The likelihood of being discharged to other than home increased with age and comorbidity count (P < 0.001). Mortality was associated with ≥3 comorbidities and age >70 years.

CONCLUSIONS

Increasing age and comorbidity are associated with poorer outcomes following RC, with comorbidity being the predominant factor. Our findings may improve surgical selection and better align patient expectations following surgery by providing estimated rates of postoperative events for patients considering RC.

Root Causes and Modifiability of 30-Day Hospital Readmissions after Radical Cystectomy for Bladder Cancer

PURPOSE

Radical cystectomy is associated with high complication and rehospitalization rates. An understanding of the root causes of hospital readmissions and the modifiability of factors contributing to readmissions may decrease the morbidity associated with radical cystectomy. We characterize the indications for rehospitalization following radical cystectomy, and determine whether these indications represent immutable patient disease and procedure factors or whether they are modifiable.

MATERIALS AND METHODS

From MarketScan® databases we identified patients younger than 65 years with a diagnosis of bladder cancer who underwent radical cystectomy between 2008 and 2011 and were readmitted to the hospital within 30 days of radical cystectomy. All associated ICD-9 codes in the index admission, subsequent outpatient claims and readmission claims were independently reviewed by 3 surgeons to determine a root cause of rehospitalization. Causes were broadly categorized as medical, surgical or infectious, and reviewers determined whether the readmission was modifiable. Multivariate logistical regression models were used to identify factors associated with rehospitalization.

RESULTS

A total of 1,163 patients were included in the study and 242 (21%) were readmitted to the hospital within 30 days. Of these readmissions 26% were considered modifiable (kappa=0.71). Of the nonmodifiable readmissions an infectious cause accounted for 52% and a medical cause accounted for 48%, whereas of the modifiable readmissions 62% were due to surgical causes, 30% to medical and 8% to infectious causes. On multivariate analysis only discharge to a skilled nursing facility was associated with modifiable (OR 6.12, 95% CI 2.32-16.14) or nonmodifiable (OR 3.27, 95% CI 1.63-6.53) hospital readmissions.

CONCLUSIONS

The majority of rehospitalizations after radical cystectomy are attributable its inherent morbidity. However, optimization of aspects of peri-cystectomy care could minimize the morbidity of radical cystectomy.

Cystic renal cell carcinoma carries an excellent prognosis regardless of tumor size

INTRODUCTION

Cystic renal cell carcinoma (cystic RCC) is thought to carry an improved prognosis relative to clear cell RCC (CCRCC); however, this is based on small case series. We used a population-based tumor registry to compare clinicopathologic features and cancer-specific mortality (CSM) of cystic RCC with those of CCRCC.

MATERIALS AND METHODS

The Surveillance, Epidemiology, and End Results database was queried for all patients diagnosed and treated for cystic RCC and CCRCC between 2001 and 2010. Clinical and pathologic factors were compared using t tests and chi-square tests as appropriate. Kaplan-Meier survival analysis compared CSM differences between cystic RCC and CCRCC.

RESULTS

A total of 678 patients with cystic RCC and 46,677 with CCRCC were identified. The mean follow-up duration was 52 and 40 months, respectively. When compared with CCRCC patients, those with cystic RCC were younger (mean age 58 vs. 61 y, P < 0.001), more commonly black (22% vs. 9%, P < 0.001), and female (45% vs. 41%, P = 0.02). Cystic RCCs were more commonly T1a tumors (66% vs. 55%, P < 0.001), well differentiated (33% vs. 16%, P < 0.001), and smaller (mean size = 3.8 vs. 4.5 cm, P < 0.001). Cystic RCC was associated with a reduction in CSM when compared with CCRCC (P = 0.002). In a subset analysis, this reduction in CSM was seen only for those with T1b/T2 tumors (P = 0.01) but not for those with T1a RCCs lesions (P = 0.31).

CONCLUSIONS

We report the largest series of cystic RCC and corroborate the findings of improved CSM when compared with CCRCC for larger tumors; however, no difference was noted in smaller tumors, suggesting that tumor biology becomes more relevant to prognosis with increasing size. These data may suggest a role for active surveillance in appropriately selected patients with small, cystic renal masses.

Underuse and underreporting of smoking cessation for smokers with a new urologic cancer diagnosis

BACKGROUND

Urothelial carcinoma of the bladder (UCB) or upper urinary tract (UCUT) and renal cell carcinoma (RCC) are smoking-related genitourinary (GU) malignancies. A new diagnosis of smoking-related GU cancer is an opportunity when smoking cessation interventions may have increased effectiveness. Underuse or underreporting of cessation tools in this setting represents potential for quality improvement. We estimated the use of smoking cessation in new smoking-related GU cancer visits based on billing claims.

METHODS

From MarketScan data, over 34 million enrollees aged 18 to 65 years, calendar years 2007 to 2011, were screened for billing codes for index UCB/UCUT or RCC and tobacco use disorder. Qualifying individuals were assessed for claims-based pharmacologic or counseling smoking cessation interventions in the 12 months following diagnosis using Current Procedural Terminology (CPT) codes and International Classification of Diseases Ninth Revision (ICD-9) codes. Multivariable logistic regression identified factors associated with smoking cessation intervention.

RESULTS

From over 111,453 incident cancers, 5,777 smokers with tobacco-related GU malignancy were identified by billing claims (40% UCB, 46% RCC, 4.2% UCUT, and 9.8% multiple cancers). Claims for intervention were rare (5.3%). Among intervention recipients, 240 (80%) had UCB and 92% had claims for either counseling or medications, only 8% had both. Most claims-based interventions (61%) were within 3 months after GU cancer diagnosis. On multivariable analysis UCB was associated increased odds of claims-based intervention (odds ratio [OR] = 6.27; 95% CI: 4.57-8.60) compared with UCUT and RCC. Other significant factors included more comorbidities (Charlson score = 1, OR = 1.50, 95% CI: 1.06-2.13; Charlson score≥2, OR = 1.89, 95% CI: 1.19-3.02 compared with Charlson score = 0) and diagnosis in the latter half of the study period (OR = 1.30, 95% CI: 1.02-1.67 compared with earlier years).

CONCLUSIONS

Although a new diagnosis of a smoking-related GU malignancy diagnosis offers greater opportunity for provider-driven smoking cessation, timely multimodal claims-based cessation interventions are underreported or underused.

National Trends in Followup Imaging after Pyeloplasty in Children in the United States

PURPOSE

Radiographic followup after pyeloplasty for the correction of ureteropelvic junction obstruction is not well defined in children. We characterize trends in frequency and modality of postoperative imaging after open and minimally invasive pediatric pyeloplasty.

MATERIALS AND METHODS

Using the MarketScan® database, we identified patients 0 to 18 years old undergoing pyeloplasty between 2007 and 2013. Followup imaging was classified as functional (diuretic renography, excretory urography) or nonfunctional (ultrasound, computerized tomography, magnetic resonance imaging). We excluded patients with less than 24 months of postoperative enrollment in MarketScan. Multivariate logistic regression was performed to determine associations between demographic variables and imaging use patterns.

RESULTS

We identified 926 patients with a mean ± SD followup of 3.6 ± 1.3 years, of whom 30% underwent minimally invasive pyeloplasty. Overall 5.9% of patients had no postoperative imaging available. Within the first 6 months postoperatively 853 patients (91%) underwent at least 1 imaging study and 192 (24%) underwent renography. Within the first 12 months postoperatively 91% of patients underwent at least 1 imaging study, most commonly ultrasound. After 12 months almost a third of the patients were not followed with imaging. Of the 71% undergoing imaging most underwent ultrasound. Younger age and female gender were independently associated with frequent imaging (at least yearly) on multivariate logistic regression.

CONCLUSIONS

Following pediatric pyeloplasty there is variation in modality and frequency of imaging followup. The majority of patients are followed with renal ultrasound, with less frequent use of functional imaging. Almost a third of patients do not undergo followup imaging after 1 year.

Overuse of antimicrobial prophylaxis in community practice urology

PURPOSE

We examined index urological surgeries to assess utilization patterns of antimicrobial prophylaxis in a large, community based population.

MATERIALS AND METHODS

From the Premier Perspectives Database we identified patients who underwent inpatient urological surgeries that are considered index procedures by the ABU (American Board of Urology), including radical prostatectomy, partial or radical nephrectomy, radical cystectomy, ureteroscopy, shock wave lithotripsy, transurethral resection of the prostate, percutaneous nephrostolithotomy, transvaginal surgery, inflatable penile prosthesis, brachytherapy, transurethral resection of bladder tumor and cystoscopy. Procedures were identified based on ICD-9 procedure codes for 2007 to 2012. Antimicrobial administration, class and duration were abstracted from patient billing data. The class and duration of antimicrobials concordant with the 2008 AUA Best Practice Policy Statement was used to determine compliance.

RESULTS

The overall compliance rate was 53%, ranging from 0.6% for radical cystectomy to 97% for shock wave lithotripsy. Antimicrobial use consistent with AUA Best Practices included the appropriate class in 67% of cases (range 34% to 80%) and the recommended duration in 78% (range 1.2% to 98%). Average prophylaxis duration for procedures for which it is recommended ranged from 1.1 days after brachytherapy to 10.3 days after radical cystectomy. The compliance rate increased from 46% overall in 2007 to 59% overall in 2012.

CONCLUSIONS

We documented considerable variation in antimicrobial prophylaxis for urological surgery. Compliance with AUA Best Practices increased with time but overall rates remain less than 60%. Efforts are needed to better understand the reasons for variation from recommended antimicrobial prophylaxis for common inpatient urological procedures to help decrease resultant complications and improve outcomes.

Prevalence of low testosterone and predisposing risk factors in men with type 1 diabetes mellitus: findings from the DCCT/EDIC

CONTEXT

Previous studies have demonstrated lower testosterone concentrations in men with type 2 diabetes mellitus. Data in men with type 1 diabetes mellitus (T1DM) are limited.

OBJECTIVE

Our objective was to determine the prevalence of low testosterone in men with T1DM and identify predisposing factors.

DESIGN, SETTING, AND PARTICIPANTS

This was a cross-sectional study of men with T1DM participating in UroEDIC (n = 641), an ancillary study of urologic complications in the Epidemiology of Diabetes Interventions and Complications (EDIC).

MAIN OUTCOME MEASURES

Total serum testosterone levels were measured using mass spectrometry, and SHBG levels were measured using sandwich immunoassay on samples from EDIC year 17/18. Calculated free testosterone was determined using an algorithm incorporating binding constants for albumin and SHBG. Low testosterone was defined as total testosterone <300 mg/dL. Multivariate regression models were used to compare age, body mass index, factors related to diabetes treatment and control, and diabetic complications with testosterone levels.

RESULTS

Mean age was 51 years. Sixty-one men (9.5%) had testosterone <300 mg/dL. Decreased testosterone was significantly associated with obesity (P < .01), older age (P < .01) and decreased SHBG (P < .001). Insulin dose was inversely associated with calculated free testosterone (P = .02). Hypertension retained a significant adjusted association with lower testosterone (P = .05). There was no observed significant relationship between lower testosterone and nephropathy, peripheral neuropathy, and autonomic neuropathy measures.

CONCLUSION

The men with T1DM in the EDIC cohort do not appear to have a high prevalence of androgen deficiency. Risk factors associated with low testosterone levels in this population are similar to the general population.

High regional variation in urethroplasty in the United States

PURPOSE

We identified clinical and regional factors associated with the use of urethroplasty vs repeat endoscopic management for urethral stricture disease.

MATERIALS AND METHODS

We analyzed claims for patients 18 to 65 years old in the 2007 to 2011 MarketScan® Commercial Claims and Encounters Database with a diagnosis of urethral stricture. The primary outcome was treatment with urethroplasty vs repeat endoscopic management, defined as more than 2 dilations or direct vision internal urethrotomies. The likelihood of urethroplasty vs repeat endoscopic management was determined for each major metropolitan area in the United States. Multivariate logistic regression was done to identify factors associated with urethroplasty.

RESULTS

We identified 41,056 patients with urethral stricture, yielding a diagnosis rate of 296/100,000 men in MarketScan. Repeat endoscopic management and urethroplasty were performed in 2,700 and 1,444 patients, respectively. Compared to patients treated with repeat endoscopic management those with urethroplasty were younger (median age 44 vs 54 years) and more likely to have a Charlson comorbidity score of 0 (84% vs 77%), have traveled out of a metropolitan area for care (34% vs 17%) and have a reconstructive urologist in the treatment metropolitan area (76% and 62%, each p <0.001). When controlling for age and Charlson comorbidity score, travel out of a metropolitan area (OR 2.7, 95% CI 2.2-3.3) and a reconstructive urologist in the treatment metropolitan area (OR 2.0, 95% CI 1.7-2.5) were associated with a greater likelihood of urethroplasty vs repeat endoscopic management.

CONCLUSIONS

Despite the well established benefits of urethroplasty compared to repeat endoscopic management a strong bias for repeat endoscopic management exists in many regions in the United States.

Burden and timing of venothrombolic events in patients younger than 65 years undergoing radical cystectomy for bladder cancer

INTRODUCTION AND OBJECTIVES

Venothrombolic events (VTEs) following radical cystectomy (RC) are a significant contributor to postoperative morbidity. A better understanding of the incidence and timing of VTE would clarify chemoprophylaxis strategies among RC patients. We sought to characterize the burden of VTE after RC by defining their timing and effect utilizing the MarketScan commercial databases.

METHODS

From MarketScan databases, we identified patients younger than 65 years undergoing RC for a primary diagnosis of bladder cancer between 2008 and 2011 with International Classification of Diseases, 9th Edition diagnosis and procedure codes. MarketScan includes inpatient and outpatient health insurance claims of 34 million enrollees annually with data from 150 employers and 13 commercial health plans. We identified the occurrence of VTE, including both pulmonary embolism and deep vein thrombosis, in patients undergoing RC by searching MarketScan for relevant International Classification of Diseases, 9th Edition codes for these diagnoses. Our primary outcome of interest was the timing of VTEs. Multivariate logistical regression models were used to identify patient factors that were associated with VTEs.

RESULTS

A total of 1,581 patients were included in our analysis. Overall, 10% of patients experienced VTEs within 90 days of RC. The incidence of postoperative VTEs during the index admission, after discharge and within 30 days of surgery, and between 31 and 90 days postoperatively was 2.9%, 3.8%, and 3.3%, respectively. Prolonged index hospitalization, discharge to a skilled nursing facility, and orthotopic neobladder urinary diversion were significantly associated with VTE within 30 days of RC.

CONCLUSION

Most VTEs occur after discharge from the index RC hospitalization. Consideration should be given to extended chemoprophylaxis in this high-risk group of patients.

Use and outcomes of extended antibiotic prophylaxis in urological cancer surgery

PURPOSE

Although perioperative antibiotic prophylaxis prevents postoperative infectious complications, national guidelines recommend cessation of antibiotics within 24 hours after the procedure. Extended antibiotic prophylaxis beyond 24 hours may contribute to hospital acquired infections such as Clostridium difficile colitis. We evaluated practice patterns of antibiotic prophylaxis in genitourinary cancer surgery and assessed the impact of antibiotic prophylaxis on hospital acquired C. difficile infections.

MATERIALS AND METHODS

We identified 59,184 patients treated with radical prostatectomy, 27,921 who underwent partial or radical nephrectomy, and 5,425 treated with radical cystectomy for prostate, kidney and bladder cancers, respectively, from the Premier Perspective Database (Premier Inc., Charlotte, North Carolina) from 2007 to 2012. We constructed hierarchical linear regression models to identify patient and hospital factors associated with extended antibiotic prophylaxis. We evaluated the association between extended antibiotic prophylaxis and C. difficile infections for patients who underwent partial or radical nephrectomy and radical cystectomy with multivariate logistic regression.

RESULTS

Surgery specific models demonstrated that hospital identity was associated with a substantial proportion of the variation in extended antibiotic prophylaxis (20% to 35% for radical prostatectomy, partial or radical nephrectomy, and radical cystectomy). Postoperative C. difficile colitis occurred in 0.02% of patients treated with radical prostatectomy, 0.23% of those treated with partial or radical nephrectomy and 1.7% of those treated with radical cystectomy. On multivariate analysis extended antibiotic prophylaxis was associated with higher odds of C. difficile infection after partial or radical nephrectomy (OR 3.79, 95% CI 2.46-5.84) and radical cystectomy (OR 1.64, 95% CI 1.12-2.39).

CONCLUSIONS

Antibiotics may be overused after genitourinary cancer surgery and this overuse is associated with hospital acquired C. difficile colitis. Efforts are needed to encourage greater compliance with evidence-based approaches to postoperative care.

Identification of underserved areas for urologic cancer care

BACKGROUND

The delivery of urologic oncology care is susceptible to regional variation. In the current study, the authors sought to define patterns of care for patients undergoing genitourinary cancer surgery to identify underserved areas for urologic cancer care in Washington State.

METHODS

The authors accessed the Washington State Comprehensive Hospital Abstract Reporting System from 2003 through 2007. They identified patients undergoing radical prostatectomy, radical cystectomy (RC), partial nephrectomy (PN), radical nephrectomy, and transurethral resection of the prostate (TURP). TURP was included for comparison as a reference procedure indicative of access to urologic care. Hospital service areas (HSAs) are where the majority of local patients are hospitalized; hospital referral regions (HRR) are where most patients receive tertiary care. The authors created multivariate hierarchical logistic regression models to examine patient and HSA characteristics associated with the receipt of urologic oncology care out of the HRR for each procedure.

RESULTS

Greater than one-half of patients went out of their HRR in 7 HSAs (11%) for radical prostatectomy, 3 HSAs (5%) for radical nephrectomy, 10 HSAs (15%) for PN, and 14 HSAs (22%) for RC. No HSAs had high export rates for TURP. Few patient factors were found to be associated with surgical care out of the HRR. High-export HSAs for PN and RC exhibited lower socioeconomic characteristics than low-export HSAs, adjusting for HSA population, race, and HSA procedure rates for PN and RC.

CONCLUSIONS

Patients living in areas with lower socioeconomic status have a greater need to travel for complex urologic surgery. Consideration of geographic delineation in the delivery of urologic oncology care may aid in regional quality improvement initiatives.

Trends in followup imaging after adult pyeloplasty

PURPOSE

Although success rates are reported to be high, radiographic followup after pyeloplasty to correct ureteropelvic junction obstruction varies in intensity and modality. We characterized postoperative care after pyeloplasty to identify imaging trends.

MATERIALS AND METHODS

Using the MarketScan® database we identified patients 17 to 65 years old treated with pyeloplasty from 2007 to 2010. Followup imaging was classified as functional (diuretic renogram or excretory urogram) and nonfunctional (ultrasound, computerized tomography or magnetic resonance imaging). The postoperative period was divided into intervals of less than 6, 6 to 12, 12 to 24, 24 to 36 and greater than 36 months. We excluded from study patients with less than 24 months of postoperative enrollment in MarketScan. Multivariate logistic regression was used to determine associations between demographic variables and imaging utilization patterns.

RESULTS

We identified 742 patients with a mean ± SD followup of 36.8 ± 3.7 months, of whom 65% underwent minimally invasive pyeloplasty. Of the patients 12% underwent no postoperative imaging. Within the first 6 months 554 patients (75%) underwent at least 1 imaging study and within the first 12 months 82% underwent at least 1 imaging study, which was most commonly functional. After 12 months 54% of patients underwent any imaging, which was most commonly nonfunctional. At least annual imaging was significantly associated with older age, female gender and longer hospital stay. Secondary procedures were required in 62 patients (8%).

CONCLUSIONS

After pyeloplasty in adulthood most patients undergo a functional imaging study within 6 months. However, after 1 year only half of patients undergo followup imaging. Variability and insufficient radiological followup may bias the belief of pyeloplasty success.

Circulating levels of 25-hydroxyvitamin D and prostate cancer prognosis

OBJECTIVES

Ecological, in vitro, and in vivo studies demonstrate a link between vitamin D and prostate tumor growth and aggressiveness. The goal of this study was to investigate whether plasma concentration of vitamin D is associated with survivorship and disease progression in men diagnosed with prostate cancer.

MATERIALS AND METHODS

We conducted a population-based cohort study of 1476 prostate cancer patients to assess disease recurrence/progression and prostate cancer-specific mortality (PCSM) risks associated with serum levels of 25(OH) vitamin D [25(OH)D].

RESULTS

There were 325 recurrence/progression and 95 PCSM events during an average of 10.8 years of follow-up. Serum levels of 25(OH)D were not associated with risk of recurrence/progression or mortality. Clinically deficient vitamin D levels were associated with an increased risk of death from other causes.

CONCLUSIONS

We did not find evidence that serum vitamin D levels measured after diagnosis affect prostate cancer prognosis. Lower levels of vitamin D were associated with risk of non-prostate cancer mortality.

Statin use in relation to prostate cancer outcomes in a population-based patient cohort study

BACKGROUND

We investigated associations between statin use begun before prostate cancer (PCa) diagnosis and PCa recurrence/progression and PCa-specific mortality (PCSM) in a prospective, population-based cohort study.

METHODS

The analysis included 1,001 PCa patients diagnosed in 2002-2005 in King County, Washington. Statin use was assessed at the time of diagnosis using a detailed in-person interview. Prostate cancer recurrence/progression events and cause-specific survival were ascertained from a follow-up survey and the SEER registry. Multivariable competing risk and Cox proportional hazards regression models were used to assess the risk of PCa outcomes according to categories of statin use.

RESULTS

Of the 1,001 PCa patients in our study, 289 men were ever users of statin drugs. During follow-up, we identified 151 PCa recurrence/progression events and 123 total deaths, including 39 PCa-specific deaths. In unadjusted analysis, the risk of PCSM was significantly lower for statin users compared to non-users (1% vs. 5% at 10 years; P < 0.01). In multivariable analysis, the adjusted hazard ratio of PCSM for statin users versus non-users was 0.19 (95% CI: 0.06, 0.56). Statin use was not associated with overall PCa recurrence/progression and other-cause mortality.

CONCLUSIONS

Statin use begun before PCa diagnosis was unrelated to PCa recurrence/progression but was associated with a decrease in risk of PCSM.

Validity and reliability of a smartphone application for the assessment of penile deformity in Peyronie's disease

INTRODUCTION

Available methods to evaluate men with Peyronie's disease (PD) are limited by the inability to accurately and reproducibly measure penile deformity. AIM.: The study aims to evaluate the performance of a smartphone application for the measurement of penile curvature and narrowing.

METHODS

A smartphone application, the University of Washington Peyronie's Examination Network (UWPEN), was developed for this purpose. To assess penile curvature, 15 single cylinders of malleable penile prostheses were molded to varying curvature angles. Three blinded observers nonsequentially measured the angle of curvature for each prosthetic cylinder using a protractor, goniometer, and UWPEN. To assess girth narrowing, six clay models of the penile shaft were constructed to represent conditions of normal, partial hourglass, circumferential hourglass, and pencil narrowing. Girth was measured using a ruler and UWPEN by the same blinded observers.

MAIN OUTCOME MEASURES

Statistical analyses compared intertest, interobserver, and intraobserver reliability using the interclass correlation coefficient (ICC). An ICC above 0.75 indicates excellent reproducibility among measurements.

RESULTS

Intertest reliability for angle measurements yielded an ICC for the three methods of 1.000. Separately, the ICC for UWPEN vs. the goniometer and protractor was 0.999 and 0.999, respectively. The interobserver ICC for UWPEN, goniometer, and protractor was 0.998, 0.999, and 1.000, respectively. Intertest reliability for girth narrowing measurements yielded an ICC of 0.991. The interobserver ICC for girth narrowing for UWPEN and the ruler was 0.978 and 0.986, respectively. Intraobserver ICC for angle measurements and girth narrowing showed high reliability for all observers and methods.

CONCLUSIONS

The performance of UWPEN is comparable with and highly correlated with angle measurements obtained from the goniometer and protractor as well as with girth narrowing measurements obtained from a ruler. Measurements are reproducible among different observers. UWPEN may provide a noninvasive, accurate, reliable, and widely accessible method to characterize and track PD over time.

Association of variants in estrogen-related pathway genes with prostate cancer risk

BACKGROUND

Through mediation of estrogen receptors, estradiol has been shown to have both carcinogenic and anti-carcinogenic effects on the prostate. We performed a population-based case-control study to investigate variants in estrogen-related genes ESR1, ESR2, CYP19A1, CYP1A1, and CYP1B1 and the potential association with risk of prostate cancer (PCa).

MATERIALS AND METHODS

We evaluated PCa risk conferred by 73 single nucleotide polymorphisms in 1,304 incident PCa cases and 1,266 age-matched controls. Analysis included stratification by clinical features and assessment of environmental modifiers.

RESULTS

There was evidence of altered risk of developing PCa for variants in ESR1, CYP1A1, and CYP1B1, however, only CYP1B1 rs1056836 retained significance after adjustment for multiple comparisons. An association with risk for more aggressive PCa was observed for variants in ESR1, ESR2, and CYP19A1, but none was significant after adjustment for multiple comparisons. There was no effect modification by obesity.

CONCLUSIONS

Germline genetic variation of these estrogen pathway genes may contribute to risk of PCa. Additional studies to validate these results and examine the functional consequence of validated variants are warranted.

Androgen metabolism and JAK/STAT pathway genes and prostate cancer risk

BACKGROUND

Prostate cancer (PC) is the most frequently diagnosed solid tumor in U.S. men. Genome-wide association studies (GWAS) have identified over 40 risk-associated single nucleotide polymorphisms (SNPs), including variants in androgen pathway genes (e.g., KLK3 and AR). Androgens are important in PC and genes involved in this pathway are therefore candidates for conferring susceptibility to PC.

METHODS

In this hypothesis-testing study, we evaluated PC risk in association with SNPs in 22 candidate genes involved in androgen metabolism or interactions with the androgen receptor (AR). A total of 187 SNPs were genotyped in 1458 cases and 1351 age-matched controls from a population-based study. PC risk was estimated using adjusted unconditional logistic regression and multinomial regression models.

RESULTS

Single SNP analyses showed evidence (p < 0.05) for associations with 14 SNPs in 9 genes: NKX3.1, HSD17B3, AKR1C3, SULT2A1, CYP17A1, KLK3, JAK2, NCOA4 and STAT3. The most significant result was observed for rs2253502 in HSD17B3 (odds ratio, OR = 0.57, 95% CI: 0.39-0.84). In addition, five SNPs in four genes (CYP17A1, HSD17B4, NCOA4, and SULT2A1) were associated with more aggressive disease (p < 0.01).

CONCLUSIONS

Our results replicate previously reported associations for SNPs in CYP17A1, HSD17B3, ARK1C3, NKX3.1, NCOA4 and KLK3. In addition, novel associations were observed for SNPs in JAK2, HSD17B4, and SULT2A1. These results will require replication in larger studies.

Genome-wide association study identifies a genetic variant associated with risk for more aggressive prostate cancer

BACKGROUND

Of the 200,000 U.S. men annually diagnosed with prostate cancer, approximately 20% to 30% will have clinically aggressive disease. Although factors such as Gleason score and tumor stage are used to assess prognosis, there are no biomarkers to identify men at greater risk for developing aggressive prostate cancer. We therefore undertook a search for genetic variants associated with risk of more aggressive disease.

METHODS

A genome-wide scan was conducted in 202 prostate cancer cases with a more aggressive phenotype and 100 randomly sampled, age-matched prostate-specific antigen screened negative controls. Analysis of 387,384 autosomal single nucleotide polymorphisms (SNPs) was followed by validation testing in an independent set of 527 cases with more aggressive and 595 cases with less aggressive prostate cancer, and 1,167 age-matched controls.

RESULTS

A variant on 15q13, rs6497287, was confirmed to be most strongly associated with more aggressive (P(discovery) = 5.20 × 10(-5), P(validation) = 0.004) than less aggressive disease (P = 0.14). Another SNP on 3q26, rs3774315, was found to be associated with prostate cancer risk; however, the association was not stronger for more aggressive disease.

CONCLUSIONS

This study provides suggestive evidence for a genetic predisposition to more aggressive prostate cancer and highlights the fact that larger studies are warranted to confirm this supposition and identify further risk variants.

IMPACT

These findings raise the possibility that assessment of genetic variation may one day be useful to discern men at higher risk for developing clinically significant prostate cancer.

Vitamin D pathway gene variants and prostate cancer prognosis

BACKGROUND

Observational studies linking vitamin D deficiency with increased prostate cancer (PCa) mortality and the pleiotropic anticancer effects of vitamin D in malignant prostate cell lines have initiated trials examining potential therapeutic benefits of vitamin D metabolites. There have been some successes but efforts have been hindered by risk of inducing hypercalcemia. A limited number of studies have investigated associations between variants in vitamin D pathway genes with aggressive forms of PCa. Increased understanding of relevant germline genetic variation with disease outcome could aid in the development of vitamin-D-based therapies.

METHODS

We undertook a comprehensive analysis of 48 tagging single-nucleotide polymorphisms (tagSNPs) in genes encoding for vitamin D receptor (VDR), vitamin D activating enzyme 1-alpha-hydroxylase (CYP27B1), and deactivating enzyme 24-hydroxylase (CYP24A1) in a cohort of 1,294 Caucasian cases with an average of 8 years of follow-up. Disease recurrence/progression and PCa-specific mortality risks were estimated using adjusted Cox proportional hazards regression.

RESULTS

There were 139 cases with recurrence/progression events and 57 cases who died of PCa. Significantly altered risks of recurrence/progression were observed in relation to genotype for two VDR tagSNPs (rs6823 and rs2071358) and two CYP24A1 tagSNPs (rs927650 and rs2762939). Three VDR tagSNPs (rs3782905, rs7299460, and rs11168314), one CYP27B1 tagSNP (rs3782130), and five CYP24A1 tagSNPs (rs3787557, rs4809960, rs2296241, rs2585428, and rs6022999) significantly altered risks of PCa death.

CONCLUSIONS

Genetic variations in vitamin D pathway genes were found to alter both risk of recurrence/progression and PCa-specific mortality.

Association of hepsin gene variants with prostate cancer risk and prognosis

BACKGROUND

Hepsin (HPN) is one of the most consistently overexpressed genes in prostate cancer and there is some evidence supporting an association between HPN gene variants and prostate cancer risk. We report results from a population-based case-control genetic association study for six tagging single nucleotide polymorphisms (tagSNPs) in the HPN gene.

METHODS

Prostate cancer risk was estimated using adjusted unconditional logistic regression in 1,401 incident prostate cancer cases diagnosed in 1993 through 1996 or 2002 through 2005 and 1,351 age-matched controls. Risks of disease recurrence/progression and prostate cancer-specific mortality were estimated using Cox proportional hazards (PH) regression in 437 cases with long-term follow-up.

RESULTS

There were 135 recurrence/progression events and 57 cases who died of prostate cancer. Contrary to some earlier studies, we found no evidence of altered risk of developing prostate cancer overall or when clinical measures of tumor aggressiveness were considered for any of the tagSNPs, assessed either individually or by haplotypes. There was no evidence of altered risks of tumor recurrence/progression or prostate cancer death associated with variants in the HPN gene.

CONCLUSIONS

Germline genetic variation of HPN does not seem to contribute to risk of prostate cancer or prognosis.

Vitamin D pathway gene variants and prostate cancer risk

Vitamin D has antiproliferative, antiangiogenic, and apoptotic properties. There is some evidence supporting an association between vitamin D-related gene variants and prostate cancer risk. We report results from this population-based case-control study of genes encoding for the vitamin D receptor (VDR), the vitamin D activating enzyme 1-alpha-hydroxylase (CYP27B1), and deactivating enzyme 24-hydroxylase (CYP24A1). Forty-eight tagging single nucleotide polymorphisms (tagSNP) were analyzed in 827 incident prostate cancer cases diagnosed from 2002 to 2005, and in 787 age-matched controls. Contrary to some earlier studies, we found no strong evidence of altered risk of developing prostate cancer overall or within clinical measures of tumor aggressiveness for any of the tagSNPs when they were assessed individually or in haplotypes.

Validating genetic risk associations for ovarian cancer through the international Ovarian Cancer Association Consortium

The search for genetic variants associated with ovarian cancer risk has focused on pathways including sex steroid hormones, DNA repair, and cell cycle control. The Ovarian Cancer Association Consortium (OCAC) identified 10 single-nucleotide polymorphisms (SNPs) in genes in these pathways, which had been genotyped by Consortium members and a pooled analysis of these data was conducted. Three of the 10 SNPs showed evidence of an association with ovarian cancer at P< or =0.10 in a log-additive model: rs2740574 in CYP3A4 (P=0.011), rs1805386 in LIG4 (P=0.007), and rs3218536 in XRCC2 (P=0.095). Additional genotyping in other OCAC studies was undertaken and only the variant in CYP3A4, rs2740574, continued to show an association in the replication data among homozygous carriers: OR(homozygous(hom))=2.50 (95% CI 0.54-11.57, P=0.24) with 1406 cases and 2827 controls. Overall, in the combined data the odds ratio was 2.81 among carriers of two copies of the minor allele (95% CI 1.20-6.56, P=0.017, p(het) across studies=0.42) with 1969 cases and 3491 controls. There was no association among heterozygous carriers. CYP3A4 encodes a key enzyme in oestrogen metabolism and our finding between rs2740574 and risk of ovarian cancer suggests that this pathway may be involved in ovarian carcinogenesis. Additional follow-up is warranted.

Vasectomy and the risk of prostate cancer

PURPOSE

While the weight of evidence shows no association overall between vasectomy and prostate cancer, there has been some suggestion that an association may exist in subgroups, such as men who have a family history of prostate cancer, men who undergo vasectomy at a younger age or when several decades have passed since the procedure. Studies of risk with long latency periods have been hampered by small sample sizes in subgroups since vasectomy only became widely used in the 1960s and generally prostate cancer has a long latency period.

MATERIALS AND METHODS

We analyzed data from a recent population based case-control study that was designed specifically to address this issue of risk in subgroups. Interviews were completed with 1,001 men diagnosed with prostate cancer from January 1, 2002 through December 31, 2005 in the Seattle-Puget Sound region and in 942 matched control men. Subjects were black and white men between the ages of 35 and 74 years. Data were analyzed using unconditional logistic regression to calculate the OR as an estimate of the relative risk of prostate cancer associated with various vasectomy parameters.

RESULTS

The prevalence of vasectomy was similar in cases and controls (36.2% and 36.1%, respectively, adjusted OR 1.0, 95% CI 0.8-1.2). There were also no associations between prostate cancer and age at vasectomy, years elapsed since vasectomy or calendar year of vasectomy.

CONCLUSIONS

These findings indicate that there is no association between vasectomy and the risk of prostate cancer.

Association of megalin genetic polymorphisms with prostate cancer risk and prognosis

PURPOSE

Megalin, an endocytic receptor expressed by prostate epithelial cells, can internalize biologically active androgens bound to sex hormone binding globulin. Genetic variation within megalin could potentially influence levels of steroid hormone uptake.

EXPERIMENTAL DESIGN

Forty haplotype-tagging single-nucleotide polymorphisms (htSNP) were analyzed in a population-based, case-control study of 553 Caucasian men who were diagnosed with prostate cancer between the ages of 40 and 64 years from the Seattle-Puget Sound region and 534 control men. Prostate cancer risk was estimated using adjusted unconditional logistic regression for both individual SNPs and haplotypes. Risks of disease recurrence/progression and prostate-specific cancer mortality were estimated using Cox proportional hazards regression.

RESULTS

We found no strong evidence of altered risk of developing prostate cancer for any of the htSNPs when they were assessed individually or in haplotypes. However, three htSNPs were significantly associated with both disease recurrence/progression and mortality. Risk of recurrence/progression alone was also associated with five additional htSNPs, and six other htSNPS showed evidence of modification by primary androgen deprivation therapy. Two additional htSNPs were significantly associated with altered risk of death from prostate cancer.

CONCLUSIONS

Preliminary results suggest that common genetic variation within the megalin gene could alter both risk of recurrence/progression and prostate-specific cancer mortality. In addition, androgen deprivation therapy effectiveness may be modified by the activity of this gene. To our knowledge, this is the first study that has examined polymorphisms within the megalin gene for associations with prostate cancer risk and outcomes.

Ovarian Cancer Risk and Polymorphisms Involved in Estrogen Catabolism

Polymorphisms within genes responsible for estrogen catabolism could alter cellular levels of genotoxic 4-hydroxylated catechol estrogens and antiangiogenic 2-methoxyestradiol, thus influencing risk of developing ovarian cancer. We carried out a population-based case-control study of 310 epithelial ovarian cancer cases and 585 controls in African-American and Caucasian women ages 35 to 54 years from Seattle, Atlanta, and Detroit metropolitan areas. Subjects were interviewed and genotyped for CYP1A1 m1, m2, m3, and m4; CYP1B1 Arg(48)Gly, Ala(119)Ser, Val(432)Leu, and Asn(453)Ser; COMT Val(158)Met; UGT1A1 A(TA)nTAA; and SULT1A1 Arg(213)His polymorphisms. Unconditional logistic regression was used to calculate odds ratios (OR). Haplotypes were inferred and analyzed using models based on expectation-maximization with progressive ligation and Bayesian coalescence theory. CYP1B1 Leu(432) carriers were at increased risk of ovarian cancer, with an adjusted OR of 1.5 (95% confidence interval, 1.1-2.3) compared with Val(432) homozygotes. The most common CYP1B1 haplotype was Arg(48)-Ala(119)-Val(432)-Asn(453). All other haplotypes with frequencies >5% contained the Leu(432) allele. In diplotype analyses, relative to women homozygous for Arg(48)-Ala(119)-Val(432)-Asn(453), women with diplotypes containing at least one Leu(432) allele had adjusted ORs ranging from 1.3 to 2.2. Among women homozygous for COMT Met(158), carriers of CYP1B1 Leu(432) had a 2.6-fold increase in risk relative to CYP1B1 Val(432) homozygotes (95% confidence interval, 1.1-5.9). This latter result is opposite in direction from a similar analysis conducted by other investigators in a different study population. No association of ovarian cancer risk was observed with any of the other polymorphisms examined, either alone or in combination.

Intramedullary nailing of proximal quarter tibial fractures

OBJECTIVE

To report the results of intramedullary nailing of proximal quarter tibial fractures with special emphasis on techniques of reduction.

DESIGN

Retrospective clinical study.

SETTING

Level 1 trauma center.

PATIENTS

During a 36-month period, 456 patients with fractures of the tibial shaft (OTA type 42) or proximal tibial metaphysis (OTA type 41A2, 41A3, and 41C2) were treated operatively at a level 1 trauma center. Thirty-five patients with 37 fractures were treated primarily with intramedullary nailing of their proximal quarter tibial fractures and formed the study group. Thirteen fractures (35.1%) were open and 22 fractures (59.5%) had segmental comminution. Three fractures had proximal intraarticular extensions.

MAIN OUTCOME MEASUREMENTS

Alignment and reduction postoperatively and at healing. An angular malreduction was defined as greater than 5 degrees in any plane.

RESULTS

Fractures extended proximally to an average of 17% of the tibial length (range, 4% to 25%). The average distance from the proximal articular surface to the fracture was 67.8 mm (range, 17 mm to 102 mm, not corrected for distance magnification, included for preoperative planning purposes only). Postoperative angulation was satisfactory (average coronal and sagittal plane deformity of less than 1 degree) as was the final angulation. Acceptable alignment was obtained in 34 of 37 fractures (91.9%). Two patients had 5-degree coronal plane deformities (one varus and one valgus), and 1 patient had a 7-degree varus deformity. Two patients with open fractures with associated bone loss underwent a planned, staged iliac crest autograft procedure postoperatively. Four patients were lost to follow-up. In the remaining 31 patients with 33 fractures, the proximal tibial fractures united without additional procedures. No patient had any change in alignment at final radiographic evaluation. Secondary procedures to obtain union at the distal fracture in segmental injuries included dynamizations (n = 3) and exchange nailing (n = 1). Complications included deep infections in 2 patients that were successfully treated.

CONCLUSIONS

Multiple techniques were required to obtain and maintain reduction prior to nailing and included attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia. Simple articular fractures and extensions were not a contraindication to intramedullary fixation. The proximal tibial fracture healed despite open manipulations. Short plate fixations to maintain this difficult reduction, either temporary or permanent, were effective.

Intramedullary nailing of distal metaphyseal tibial fractures

BACKGROUND

The treatment of distal metaphyseal tibial fractures remains controversial. This study was performed to evaluate the results of intramedullary nailing of distal tibial fractures located within 5 cm of the ankle joint.

METHODS

Over a sixteen-month period at two institutions, thirty-six tibial fractures that involved the distal 5 cm of the tibia were treated with reamed intramedullary nailing with use of either two or three distal interlocking screws. Ten fractures with articular extension were treated with supplementary screw fixation prior to the intramedullary nailing. Radiographs were reviewed to determine the immediate and final alignments and fracture-healing. The Short Form-36 (SF-36) and Musculoskeletal Function Assessment (MFA) questionnaires were used to evaluate functional outcome.

RESULTS

Acceptable radiographic alignment, defined as <5 degrees of angulation in any plane, was obtained in thirty-three patients (92%). No patient had any change in alignment between the immediate postoperative and the final radiographic evaluation. Complications included one deep infection and one iatrogenic fracture at the time of the intramedullary nailing. Six patients could not be followed. The remaining thirty fractures united at an average of 23.5 weeks. Three patients with associated traumatic bone loss underwent a staged autograft procedure, and they had fracture-healing at an average of 44.3 weeks. The functional outcome was determined at a minimum of one year for nineteen patients and at a minimum of two years (average, 4.5 years) for fifteen patients. At one year, there were significant limitations in several domains despite fracture union and maintenance of alignment, but there was improvement in the MFA scores with time.

CONCLUSIONS

Intramedullary nailing is an effective alternative for the treatment of distal metaphyseal tibial fractures. Simple articular extension of the fracture is not a contraindication to intramedullary fixation. Functional outcomes improve with time.

An association between functional second metatarsal length and midfoot arthrosis

BACKGROUND

Primary tarsometatarsal arthrosis is relatively uncommon. The etiology of osteoarthritis in the foot is poorly understood, and it is possible that mechanical or anatomic factors play a role.

METHODS

We compared the relative length of the metatarsals in patients with idiopathic arthrosis of the midfoot with that in a group of controls without arthrosis. We analyzed the radiographs of all patients who had had an arthrodesis of the first, second, and third tarsometatarsal joints to treat arthrosis during a three-year period at a tertiary teaching hospital. We excluded patients with a history of inflammatory arthritis, trauma, or Charcot arthropathy. Nine patients (fifteen feet), seven women and two men with an average age of 64.2 years, met the inclusion criteria. We compared them with a control group consisting of the uninjured feet of patients with an acute traumatic injury to the hindfoot and the feet of volunteers with no foot problems. We measured the first, second, and fourth metatarsal lengths and the intermetatarsal angles on weight-bearing anteroposterior radiographs. We also measured the length of the first metatarsal relative to the long axis of the second metatarsal to define the functional first metatarsal length. The ratios of metatarsal lengths and the ratios of functional lengths were used for analysis to minimize differences in foot size and differences caused by radiographic magnification. Statistical comparisons between groups were then carried out.

RESULTS

In the study group, the length of the first metatarsal was, on the average, 77.0% of the length of the second metatarsal, whereas, in the control group, the first metatarsal length was an average of 82.0% of the second metatarsal length. The functional length of the second metatarsal was, on the average, 18.6% greater than that of the first metatarsal in the study group and only an average of 4.1% greater than that of the first metatarsal in the control group. Both differences were significant (p < 0.0004 and p < 0.0001, respectively).

CONCLUSIONS

Patients with midfoot arthrosis had a different ratio of the first to the second metatarsal length than did a similarly aged cohort without midfoot arthrosis. The patients had a relatively short first metatarsal or a relatively long second metatarsal, or both. Midfoot arthrosis may have a mechanical etiology. Recognition of risk factors is the first step in developing prevention strategies.