Is biopsy Gleason sum an independent predictor of biochemical progression following radical prostatectomy after adjusting for the pathological Gleason sum?

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Background: Biopsy Gleason sum is a known important predictor of PSA failure following radical prostatectomy (RP). However, it is unclear whether it remains predictive of outcome after surgery when the pathological Gleason sum is known. Methods: We determined the association between biopsy Gleason sum and biochemical progression after correcting for both pre-operative and post-operative characteristics including pathological Gleason sum among 1,931 men treated with RP between 1988 and 2005 within the SEARCH Database. Gleason sum was examined as a categorical variable of 2–6, 3+4, and ≥4+3. Results: Higher biopsy Gleason sums were associated with increased prevalence of extra-capsular extension (p < 0.001), positive surgical margins (p < 0.001), seminal vesicle invasion (p < 0.001), positive lymph nodes (p < 0.001), and biochemical progression (log rank, p < 0.001). After adjusting for only pre-operative characteristics, both biopsy Gleason sums of 3+4 (p = 0.004) and ≥4+3 (p < 0.001) were associated with increased risk of biochemical progression when compared to biopsy Gleason sums of 6 or less. After further adjusting for multiple pathological characteristics including pathological Gleason sum, the association between higher biopsy Gleason sum and risk of progression was little changed in that men with biopsy Gleason sums of 3+4 (p = 0.001) and ≥4+3 (p < 0.001) were significantly more likely to progress. Furthermore, when stratified by pathological Gleason sum, higher biopsy Gleason sums were associated with increased risk of biochemical progression within each pathological Gleason sum category (log-rank, p ≤ 0.007). Conclusions: Biopsy Gleason sum remains a strong predictor of outcome even when the pathological Gleason sum is known. If confirmed at other centers, incorporation of biopsy Gleason sum into post-operative nomograms designed to predict risk of progression might improve model precision.

No significant financial relationships to disclose.

Transurethral needle ablation versus transurethral resection of the prostate for the treatment of symptomatic benign prostatic hyperplasia: 5-year results of a prospective, randomized, multicenter clinical trial

PURPOSE

We report the 5-year efficacy and safety of transurethral needle ablation of the prostate (TUNA) compared to transurethral resection of the prostate (TURP) for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

A total of 121 men 50 years or older with LUTS secondary to BPH a minimum of 3 months in duration were enrolled in this prospective, randomized clinical trial at 7 medical centers across the United States. Of the participants 65 (54%) were randomly selected to receive TUNA and 56 (46%) were selected to receive TURP. International Prostate Symptom Score, quality of life, peak urinary flow rate, post-void residual urinary volume, and prostate size and configuration were evaluated before the procedure and then annually for 5 years after the procedure. Adverse events were also recorded throughout the study.

RESULTS

Improvement from baseline for TUNA and TURP retained statistical significance at each interval for International Prostate Symptom Score, quality of life and peak flow rate. Post-void residual volume was statistically significant at all time points for TURP and at year 5 for TUNA. The TURP group reported 41% retrograde ejaculation, while the TUNA group reported none. The incident of erectile dysfunction, incontinence and stricture formation was also greater in TURP than in TUNA cases with significantly fewer adverse events for TUNA than for TURP.

CONCLUSIONS

The results of this study demonstrate stable treatment outcomes after 5 years of followup and suggest that TUNA is an attractive treatment option for men with LUTS due to BPH.

Gene expression patterns in renal cell carcinoma assessed by complementary DNA microarray

Renal cell carcinoma comprises several histological types with different clinical behavior. Accurate pathological characterization is important in the clinical management of these tumors. We describe gene expression profiles in 41 renal tumors determined by using DNA microarrays containing 22,648 unique cDNAs representing 17,083 different UniGene Clusters, including 7230 characterized human genes. Differences in the patterns of gene expression among the different tumor types were readily apparent; hierarchical cluster analysis of the tumor samples segregated histologically distinct tumor types solely based on their gene expression patterns. Conventional renal cell carcinomas with clear cells showed a highly distinctive pattern of gene expression. Papillary carcinomas formed a tightly clustered group, as did tumors arising from the distal nephron and the normal kidney samples. Surprisingly, conventional renal cell carcinomas with granular cytoplasm were heterogeneous, and did not resemble any of the conventional carcinomas with clear cytoplasm in their pattern of gene expression. Characterization of renal cell carcinomas based on gene expression patterns provides a revised classification of these tumors and has the potential to supply significant biological and clinical insights.

National health insurance in the United States: a drama in too many acts

Responding to the question, "Universal Health Care: How Can We Get There from Here?," this paper describes the history of governmental health insurance in the United States, analyzes the factors that have proved to be crucial to its establishment in other countries, and concludes that without a strong Labor Party, there will be no national health insurance, no universal healthcare system in the United States.

The development and prevention of cardiovascular disease risk factors: socioenvironmental influences

In Third World countries, coronary heart disease is more frequent in the upper classes. In industrial countries such as the United States, Canada, and the United Kingdom, there has been a widening social class difference in the opposite direction. Yet the social class differences have been largely ignored in the development of public health programs to prevent cardiovascular disease. This paper presents specific recommendations to correct this glaring defect, including giving priority to the reduction of risk factor prevalence among low-income blue collar and white collar workers, strengthening regulatory, taxation, and other measures that directly impact all classes of the population, reversing the declining living standards of large segments of the U.S. population which result from current economic and political policy, and greatly expanding the resources available for public health programs from their grossly inadequate level at the present time.

The neoliberal triad of anti-health reforms: government budget cutting, deregulation, and privatization

This paper presents the author's experiences and perceptions of the neoliberal triad of anti-health reforms--government budget cutting, deregulation, and privatization--which have been promulgated worldwide by the World Bank and the International Monetary Fund. The causes of this phenomenon are analyzed, and specific alternative health policies are recommended. The role of epidemiology in documenting the damages to health resulting from the anti-health reforms is discussed. Finally, the paper emphasizes the need not only for national organizational strategies but for action on the international level. The opponents of privatization need to meet together, to exchange experiences, and to develop effective strategies on a world scale that can be applied in industrial and developing nations.

Violence in a violent society

The descriptive epidemiology of violence in the United States is presented. The reasons for the high homicide rates are explored by describing the historical development of violence in Colombia, a developing country with very high homicide rates, and in the United States, which has extraordinarily high homicide rates in comparison with other highly industrialized countries. The historical factors in the United States that contribute to the high violence rates include the genocide of the Indian population, the slave system, and the increasing militarization of the country's economy, ideology, and governmental policy. It is clear that "the United States is a high-violence environment," that it is indeed a violent society.

C.-E. A. Winslow: scientist, activist, and theoretician of the American public health movement throughout the first half of the twentieth century

C.-E. A. Winslow was the leading theoretician of the American public health movement during the entire first half of the twentieth century. An eminent bacteriologist, he subsequently made outstanding scientific contributions to occupational health and to the hygiene of housing. As activist, theoretician and historian, he played an important role in environmental health, epidemiology and disease prevention, public health administrative practice, health education, public health nursing, mental health, medical care, and the improvement of living standards. When he died in 1957, the American Journal of Public Health commented that "For a long half century Professor Winslow could be found always at the thick of the struggle for the people's health. In whatever area new gains appeared possible of achievement, there he would be--planning, inspiring, leading, or digging in to hold the advance."

Epidemiology and health policy in the Americas: meeting the neoliberal challenge

This paper analyses the anti-health policies and programs that are being pursued by neoliberal governments on a global scale, and that are being sold to the public by labeling them as "health reforms." The role of epidemiologists in this situation is to strengthen opposition to these anti-health reforms by documenting their effects on preventive and therapeutic health services and on the health status of the population. Major difficulties in this regard are discussed. There is a great need for epidemiologists to move boldly forward to attack the major diseases that afflict the Americas today. Two examples of high-priority programs are discussed: the achievement of safe water supplies by newly developed, low-cost community-based initiatives, and the long over-due organization of effective campaigns against cardiovascular disease. The establishment of specific, concrete Health Objectives at all levels of government--national, state/provincial, and local--must become the central focus of public health policy and action throughout the Americas. Epidemiologists are urged to take leadership in advocating and achieving this fundamentally epidemiologic approach.

Lean and mean: the quality of care in the era of managed care

This paper reviews the genesis of managed care and the reasons for its rapid growth. The effects of the differing incentives of traditional and managed-care plans on quality of care are described. There is an urgent need for federal, state and local health departments to monitor and regulate the quantity and quality of health care provided by all types of insurance plans. The elements of such a program are outlined, and the need for adequate funding as well as political and technical leadership is emphasized. This should become a major priority issue for the public health movement in the United States.

The development and prevention of cardiovascular disease risk factors: socioenvironmental influences

In Third World countries, coronary heart disease is more frequent in the upper classes. In industrial countries such as the United States, Canada and the United Kingdom, there has been a widening social class difference in the opposite direction. Yet the social class differences have been largely ignored in the development of public health programs to prevent cardiovascular disease. This paper presents specific recommendations to correct this glaring defect, including giving priority to the reduction of risk factor prevalence among low-income blue collar and white collar workers; strengthening regulatory, taxation and other measures that directly impact all classes of the population; reversing the declining living standards of large segments of the U.S. population which result from current economic and political policy; and greatly expanding the resources available for public health programs from their grossly inadequate level.

Towards a national health program. The components of care

The writer contends that incorporating all the components of health, not only medical care, should be our goal as we strive for a comprehensive national system. In discussing the prospects for a national health program, Terris draws on the ideas and observations of Henry Sigerist, the noted medical historian who brilliantly analyzed the political preconditions for the establishment of national health insurance. Finally, he argues that the lessons of Canada offer progressives here a valuable point of departure.