Use of advanced treatment technologies among men at low risk of dying from prostate cancer

Prostate Cancer Registries: Current Status and Future Directions

CONTEXT

Disease-specific registries that enroll a considerable number of patients play a major role in prostate cancer (PCa) research.

OBJECTIVE

To evaluate available registries, describe their strengths and limitations, and discuss the potential future role of PCa registries in outcomes research.

EVIDENCE ACQUISITION

We performed a literature review of the Medline, Embase, and Web of Science databases. The search strategy included the terms prostate cancer, outcomes, statistical approaches, population-based cohorts, registries of outcomes, and epidemiological studies, alone or in combination. We limited our search to studies published between January 2005 and January 2015.

EVIDENCE SYNTHESIS

Several population-based and prospective disease-specific registries are currently available for prostate cancer. Studies performed using these data sources provide important information on incidence and mortality, disease characteristics at presentation, risk factors, trends in utilization of health care services, disparities in access to treatment, quality of care, long-term oncologic and health-related quality of life outcomes, and costs associated with management of the disease. Although data from these registries have some limitations, statistical methods are available that can address certain biases and increase the internal and external validity of such analyses. In the future, improvements in data quality, collection of tissue samples, and the availability of data feedback to health care providers will increase the relevance of studies built on population-based and disease-specific registries.

CONCLUSIONS

The strengths and limitations of PCa registries should be carefully considered when planning studies using these databases. Although randomized controlled trials still provide the highest level of evidence, large registries play an important and growing role in advancing PCa research and care.

PATIENT SUMMARY

Several population-based and prospective disease-specific registries for prostate cancer are currently available. Analyses of data from these registries yield information that is clinically relevant for the management of patients with prostate cancer.

Robot-assisted Radical Prostatectomy and Extended Pelvic Lymph Node Dissection in Patients with Locally-advanced Prostate Cancer

BACKGROUND

Limited data are available on the role of robot-assisted radical prostatectomy (RARP) in patients with locally advanced prostate cancer (PCa).

OBJECTIVE

To describe our surgical technique of extrafascial RARP and extended pelvic lymph node dissection (ePLND) in locally advanced PCa.

DESIGN, SETTING, AND PARTICIPANTS

Ninety-four patients with clinical stage ≥T3 undergoing RARP with ePLND at three European centers between 2011 and 2015 were retrospectively evaluated.

SURGICAL PROCEDURE

Surgery was performed using the DaVinci Si system. The anatomically defined ePLND included nodes overlying the external iliac axis, those in the obturator fossa, and around the internal iliac artery up to the ureter. RARP was performed using an extrafascial approach where the Denonvillers' fascia was dissected free and left on the posterior surface of the seminal vesicles.

MEASUREMENTS

Perioperative outcomes consisted of operative time, blood loss, length of hospital stay, and complications occurred within 30 d after surgery. Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen values ≥0.2ng/ml. Kaplan-Meier analyses assessed time to BCR and clinical recurrence. Multivariable Cox regression analyses assessed predictors of BCR.

RESULTS AND LIMITATIONS

Median operative time, blood loss, and length of hospital stay were 230min, 200ml, and 6 d. Overall, 12 (12.7%) patients experienced complications and five (5.3%), four (4.3%), and three (3.2%) patients had Clavien I, II, and III/IV complications. Overall, 72 (76.6%), 35 (37.2%), and 30 (32.3%) patients had pT3/4, pN1, and positive margins. The median number of nodes removed was 16. Overall, 19 (20.2%) and 21 (22.3%) patients received adjuvant radiotherapy and hormonal therapy. The median follow-up was 23.5 mo. At 3-yr follow-up, the BCR- and clinical recurrence-free survival rates were 63.3% and 95.8%. Pathologic stage, Gleason score, and positive margins represented predictors of BCR (all p≤0.03). Our study is limited by its retrospective nature and by the follow-up duration.

CONCLUSIONS

RARP represents a well-standardized, safe, and oncological effective option in patients with locally advanced PCa. Pathologic stage, Gleason score, and positive margins should be considered to select patients for multimodal approaches.

PATIENT SUMMARY

Robot-assisted surgery represents a well-standardized, safe, and oncological effective option in men with locally advanced prostate cancer. Two out of three patients treated with this approach are free from recurrence at 3-yr follow-up. Pathologic stage, Gleason score, and positive surgical margins represent predictors of BCR and should be considered to select patients for multimodal approaches.

Surgeon and Hospital Level Variation in the Costs of Robot-Assisted Radical Prostatectomy

PURPOSE

We assessed surgeon and hospital level variation in robot-assisted radical prostatectomy costs and predictors of high and low cost surgery.

MATERIALS AND METHODS

The study population consisted of a weighted sample of 291,015 men who underwent robot-assisted radical prostatectomy for prostate cancer by 667 surgeons at 197 U.S. hospitals from 2003 to 2013. We evaluated 90-day direct hospital costs (2014 USD) in the Premier Hospital Database. High costs per robot-assisted radical prostatectomy were those above the 90th percentile and low costs were those below the 10th percentile.

RESULTS

Mean hospital cost per robot-assisted radical prostatectomy was $11,878 (95% CI $11,804-$11,952). Mean cost was $2,837 (95% CI $2,805-$2,869) in the low cost group vs $25,906 (95% CI $24,702-$25,490) in the high cost group. Nearly a third of the variation in robot-assisted radical prostatectomy cost was attributable to hospital characteristics and more than a fifth was attributable to surgeon characteristics (R-squared 30.43% and 21.25%, respectively). High volume surgeons and hospitals (90th percentile or greater) had decreased odds of high cost surgery (surgeons: OR 0.24, 95% CI 0.11-0.54; hospitals: OR 0.105, 95% CI 0.02-0.46). The performance of robot-assisted radical prostatectomy at a high volume hospital was associated with increased odds of low cost robot-assisted radical prostatectomy (OR 839, 95% CI 122-greater than 999).

CONCLUSIONS

This study provides insight into the role of surgeons and hospitals in robot-assisted radical prostatectomy costs. Given the substantial variability, identifying and remedying the root cause of outlier costs may yield substantial benefits.

Life Expectancy and Variation in Treatment for Early Stage Kidney Cancer

PURPOSE

Patients with limited life expectancy are at risk for overtreatment of T1a kidney cancer. We sought to determine patterns of treatment for T1a kidney cancer in a nationally representative sample of patients with life expectancy less than 10 and less than 5 years.

MATERIALS AND METHODS

We sampled 9,825 patients older than 65 years with clinical T1a kidney cancer diagnosed between 2000 and 2010 from the SEER (Surveillance, Epidemiology and End Results)-Medicare database. We performed competing risks regression to model survival by age/comorbidity and identified patients with life expectancy less than 10 and less than 5 years. Multivariate logistic regression was used to determine the probability of aggressive treatment with surgery or ablation among those with limited life expectancy.

RESULTS

Life expectancy was less than 10 years in patients 66 to 80 years old with a Charlson score of 3+, in those 80 to 84 years old with a Charlson score of 1+ and in all patients 85 years old or older. Among those with life expectancy less than 10 years the multivariate probability of aggressive treatment was 85%, 84%, 82%, 75% and 50% in those 66 to 69, 70 to 74, 75 to 79, 80 to 84 and 85 years old or older, respectively. In those with life expectancy less than 10 years who were treated aggressively treatment was radical nephrectomy in 61%, partial nephrectomy in 24% and ablation in 14%. Among those with life expectancy less than 5 years (age 85 years or greater with a Charlson score of 3+) the multivariate probability of aggressive treatment was 41% and more often surgery than ablation (68% vs 32% of patients).

CONCLUSIONS

The majority of patients with life expectancy less than 10 years and a significant minority with life expectancy less than 5 years were treated with surgery or ablation for T1a kidney cancer. Life expectancy should be better incorporated into treatment decision making for early stage kidney cancer.

Identification of candidates for observation

PURPOSE OF REVIEW

The clinical value of active surveillance may still be limited due to acceptance and considerable misclassification rates, and inadequate follow-up criteria. This review focuses on the most recent developments in the use of active surveillance and patient-specific factors that may be used to identify patients suitable for this strategy.

RECENT FINDINGS

The number of patients diagnosed with low-risk prostate cancer has risen. Active surveillance acceptance rates are increasing, but still limited and varying importantly (2-49%). Misclassification is inevitable in all currently used protocols, although most of these patients still have relatively favorable-risk prostate cancer. African-American race, obese, and older-aged patients show more unfavorable intermediate results in an active surveillance situation. These are unlikely to be explained by the small differences in preoperative characteristics only. Psychological profiling may also be added to the selection process. Most studies report intermediate endpoints only.

SUMMARY

Patient-specific factors may be incorporated when identifying patients for active surveillance. This does not imply that active surveillance is not justified in specific groups, but may suggest the need for an intensified and personalized selection, instead of a one-size-fits-all approach.

Current clinical challenges in prostate cancer

Prostate cancer is the most common malignancy and the second leading cause of cancer death in men in the United States. Close to $12 billion are spent annually on the treatment of prostate cancer in the US alone. Yet still there remain tremendous controversies and challenges that exist in all facets of the disease. This review and discussion will focus on issues and challenges for clinicians and patients diagnosed with the disease.

Appropriate risk stratification for men with newly diagnosed prostate cancer is an appropriate first step for all patients. Once risk-stratified, for those with low-risk of death, it is increasingly recognized that overtreatment creates an unnecessary burden for many patients. This is particularly evident when put in the context of competing comorbidities in an elderly population. For those with advanced or high-risk localized disease, under-treatment remains too common. For those with a high-risk of recurrence or failure following primary treatment, adjuvant or salvage therapies are an option, but how and when to best deploy these treatments are controversial.

Recently, tremendous progress has been made for those with advanced disease, in particular those with metastatic castrate-resistant prostate cancer (mCRPC). Within the last 4 years, five novel FDA approved agents, acting through distinct mechanisms have been FDA approved for mCRPC. With the introduction of these new agents a host of new challenges have arisen. Timing, sequencing and combinations of these novel agents are welcomed challenges when compared with the lack of available therapies just a few years ago.

In this summary of current clinical challenges in prostate cancer we review critical recent studies that have created or shifted the current paradigms of treatment for prostate cancer. We will also highlight ongoing issues that continue to challenge our field.

A survey of patient expectations regarding sexual function following radical prostatectomy

OBJECTIVE

To assess the understanding of patients, who had previously undergone radical prostatectomy (RP), about their postoperative sexual function, as clinical experience suggests that some RP patients have unrealistic expectations about their long-term sexual function.

PATIENTS AND METHODS

Patients presenting within 3 months of their open RP or robot-assisted laparoscopic prostatectomy (RALP) were questioned about the sexual function information that they had received preoperatively. Patients were questioned about erectile function (EF), postoperative ejaculatory status, orgasm, and postoperative penile morphology changes. Statistical analyses were performed to assess for differences between patients who underwent open RP vs RALP.

RESULTS

In all, 336 consecutive patients (from nine surgeons) with a mean (SD) age of 64 (11) years had the survey instrument administered (216 underwent open RP and 120 underwent RALP). There were no significant differences in patient age or comorbidity profiles between the two groups. Only 38% of men had an accurate recollection of their nerve-sparing status. The mean (SD) elapsed time after RP at the time of postoperative assessment was 3 (2) months. RALP patients expected a shorter EF recovery time (6 vs 12 months, P = 0.02), a higher likelihood of recovery back to baseline EF (75% vs 50%, P = 0.01), and a lower potential need for intracavernosal injection therapy (4% vs 20%, P = 0.01). Almost half of all patients were unaware that they were rendered anejaculatory by their surgery. None of the RALP patients and only 10% of open RP patients recalled being informed of the potential for penile length loss (P < 0.01) and none were aware of the association between RP and Peyronie's disease.

CONCLUSIONS

Patients who have undergone RP have largely unrealistic expectations about their postoperative sexual function.

The Effect of the Diffusion of the Surgical Robot on the Hospital-level Utilization of Partial Nephrectomy

INTRODUCTION

The rapid diffusion of the surgical robot has been controversial because of the technology's high costs and its disputed marginal benefit. Some, however, have suggested that adoption of the robot may have improved care for patients with renal malignancy by facilitating partial nephrectomy, an underutilized, technically challenging procedure believed to be less morbid than radical nephrectomy. We sought to determine whether institutional acquisition of the robot was associated with increased utilization of partial nephrectomy.

METHODS

We used all payer data from 7 states to identify 21,569 nephrectomies. These patient-level records were aggregated to the hospital-level then merged with the American Hospital Association Annual Survey and publicly available data on timing of robot acquisition. We used a multivariable difference-in-difference model to assess at the hospital-level whether robot acquisition was associated with an increase in the proportion of partial nephrectomy, adjusting for hospital nephrectomy volume, year of surgery, and several additional hospital-level factors.

RESULTS

In the multivariable-adjusted differences-in-differences model, hospitals acquiring a robot between 2001 and 2004 performed a greater proportion of partial nephrectomy in both 2005 (29.9% increase) and 2008 (34.9% increase). Hospitals acquiring a robot between 2005 and 2008 also demonstrated a greater proportion of partial nephrectomy in 2008 (15.5% increase). In addition, hospital nephrectomy volume and urban location were also significantly associated with increased proportion of partial nephrectomy.

CONCLUSIONS

Hospital acquisition of the surgical robot is associated with greater proportion of partial nephrectomy, an underutilized, guideline-encouraged procedure. This is one of the few studies to suggest robot acquisition is associated with improvement in quality of patient care.

The outcome and prognostic factors for lymph node recurrence after node-sparing definitive external beam radiotherapy for localized prostate cancer

Background

The prognostic factors for the recurrence of lymph node (LN) metastasis after dose-escalated radiotherapy (RT) in prostate cancer patients have not been well investigated. We report the prognostic factors and outcomes in patients receiving salvage treatment for LN recurrence after high-dose intensity-modulated RT (IMRT).

Methods

We studied a cohort of 419 patients with localized prostate adenocarcinoma undergoing definitive IMRT (78 Gy). LN recurrence was diagnosed by size criteria using computed tomography (CT) or magnetic resonance imaging, or abnormal uptake of ¹⁸F-fluorocholine by LNs on positron emission tomography/CT. Overall survival and LN recurrence-free survival (LNRFS) were calculated, and prognostic factors were evaluated.

Results

With a median follow-up of 60 months, 18 patients (4.3 %) had LN recurrence and a significantly lower 5-year overall survival rate (60 vs. 90 %, p = 0.003). Univariate analysis showed that T3/T4 stage (p = 0.003), Gleason score >7 (p < 0.001), and estimated risk of pelvic LN involvement of >30 % by the Roach formula (p = 0.029) were associated with significantly lower LNRFS. On multivariate analysis, high Gleason score (hazard ratio = 5.99, p = 0.007) was the only independent factor. The 1/2-year overall survivals after LN recurrence were 67/54 %. Patients with isolated LN recurrence (p = 0.003), prostate-specific antigen (PSA) doubling time >5 months (p = 0.009), interval between PSA nadir and biochemical failure >12 months (p = 0.035), and PSA <10 ng/ml at LN recurrence (p = 0.003) had significantly better survival. Patients with isolated LN recurrence had significantly better survival when treated with combined RT and hormones than when treated with hormones alone (p = 0.011).

Conclusions

Gleason score of >7 may predict LN recurrence in prostate cancer patients treated with definitive IMRT. Small number of patients limits the extrapolation of this risk with the primary treatment strategy. Combined RT and hormones may prolong survival in patients with isolated LN recurrence.

Expectant management of veterans with early-stage prostate cancer

BACKGROUND

For certain men with low-risk prostate cancer, aggressive treatment results in marginal survival benefits while exposing them to urinary and sexual side effects. Nevertheless, expectant management has been underused. In the current study, the authors evaluated the association between various factors and expectant management use among veterans diagnosed with prostate cancer.

METHODS

The authors identified men diagnosed with prostate cancer in 2008. The outcome of interest was use of expectant management, based on documentation captured through an in-depth chart review. Multivariable regression models were fit to examine associations between use of expectant management and patient demographics, cancer severity, and facility characteristics. The authors assessed variation across 21 tertiary care regions and 52 facilities by generating predicted probabilities for receipt of expectant management.

RESULTS

Expectant management was more common among patients aged ≥75 years (40% vs 27% for those aged < 55 years; odds ratio, 2.57) and those with low-risk tumors (49% vs 20% for patients with high-risk tumors; odds ratio, 5.35). There was no association noted between patient comorbidity and receipt of expectant management (P = .90). There were also no associations found between facility factors and use of expectant management (all P>.05). Among ideal candidates for expectant management, receipt of expectant management varied considerably across individual facilities (0%-85%; P<.001).

CONCLUSIONS

Patient age and tumor risk were found to be more strongly associated with use of expectant management than patient comorbidity. Although use of expectant management appears broadly appropriate, there was variation in expectant management noted between hospitals that was apparently not attributable to facility factors. Research determining the basis of this variation, with a focus on providers, will be critical to help optimize prostate cancer treatment for veterans.

Probability modeling of the number of positive cores in a prostate cancer biopsy session, with applications

Among men, prostate cancer (CaP) is the most common newly diagnosed cancer and the second leading cause of death from cancer. A major issue of very large scale is avoiding both over-treatment and under-treatment of CaP cases. The central challenge is deciding clinical significance or insignificance when the CaP biopsy results are positive but only marginally so. A related concern is deciding how to increase the number of biopsy cores for larger prostates. As a foundation for improved choice of number of cores and improved interpretation of biopsy results, we develop a probability model for the number of positive cores found in a biopsy, given the total number of cores, the volumes of the tumor nodules, and - very importantly - the prostate volume. Also, three applications are carried out: guidelines for the number of cores as a function of prostate volume, decision rules for insignificant versus significant CaP using number of positive cores, and, using prior distributions on total tumor size, Bayesian posterior probabilities for insignificant CaP and posterior median CaP. The model-based results have generality of application, take prostate volume into account, and provide attractive tradeoffs of specificity versus sensitivity. Copyright © 2015 John Wiley & Sons, Ltd.

Identification of pathologically favorable disease in intermediate-risk prostate cancer patients: Implications for active surveillance candidates selection

BACKGROUND

Intermediate-risk prostate cancer (PCa) represents a heterogeneous disease, where a non-negligible proportion of patients harbor favorable pathologic characteristics and are potentially eligible for active surveillance (AS). We aimed at developing a model for the identification of pathologically favorable PCa at radical prostatectomy (RP) among intermediate-risk patients.

METHODS

Overall, 3,821 intermediate-risk patients treated with RP at two centers between 2005 and 2013 were identified. Pathologically favorable PCa was defined as low-grade organ-confined disease. Age, biopsy Gleason, PSA density (PSAD), and the percentage of positive cores were included in multivariable logistic regression analyses predicting favorable PCa and formed the basis for a logistic regression-based risk calculator. The internally validated discrimination and calibration of the risk calculator were quantified using 200 bootstrap resamples. Decision curve analysis (DCA) provided an estimate of the net benefit obtained using this model versus treating no one and treating everyone.

RESULTS

Overall, 10.0% of all intermediate risk patients had favorable disease. In multivariable analyses, patients with biopsy Gleason score ≤6 had higher probability of favorable disease compared to those with higher-grade disease (P < 0.001). Similarly, age, PSAD, and percentage of positive cores were associated with the probability of favorable disease (all P ≤ 0.01). The risk calculator achieved a validated accuracy of 82.5%. The DCA showed that our prediction model is better than both treating no one and treating everyone.

CONCLUSIONS

One out of ten intermediate-risk patients harbors favorable disease at RP. Our novel, pre-operative, validated risk calculator may help clinicians identifying patients who could be considered for conservative therapy approaches such as AS.

Treatment of localized prostate cancer in elderly patients

Prostate cancer is a disease of the elderly. According to National Cancer Institute, more than 56.7% of incident cases are diagnosed and more than 90% of cancer specific deaths occur in men greater than 65 years of age. Despite equivalent oncologic outcomes with treatment, primary local therapy is often deferred in elderly men with high-risk prostate cancer, in part due to concerns that post surgery quality of life (QOL) functional outcomes compare poorly to younger men. Our aim in this editorial is to discuss the functional and oncological outcomes in management of elderly with localized prostate cancer.

Treatment patterns for older veterans with localized prostate cancer

OBJECTIVE

Concerns about over-treatment have led to practice guidelines discouraging active treatment of prostate cancer (PCa) in men with limited life expectancies and/or low-risk tumors. We evaluated treatment patterns for older veterans with localized PCa, particularly those with low-risk features.

METHODS

We used VA Cancer Registry data to identify men aged 65+ diagnosed with clinically localized PCa between January 1st, 2003 and December 31st, 2008. We obtained baseline data on demographics, tumor characteristics, comorbidities, and initial treatment within 6 months of diagnosis: radical prostatectomy, radiotherapy, primary androgen-deprivation therapy (PADT), or no active treatment. National VA surveys provided facility data, including academic affiliation, availability of oncologic specialists, and distance to radiotherapy facilities. Multinomial regression analyses determined associations between patient and facility characteristics and cancer treatment for men with localized (stage<III) and low-risk PCa (stage≤IIa, PSA<10ng/mL, Gleason ≤6).

RESULTS

17,206 veterans had localized PCa, 32% age 75+, 12% had comorbidity scores ≥3, and 33% had low-risk tumors. Overall, 39% received radiotherapy, 6% surgery, 20% PADT, and 35% no active treatment. For those with low-risk cancers, older men (RR=0.36, 95% CI 0.30-0.43) and sicker men (RR=0.75, 95% CI 0.62-0.90) were less likely to receive surgery or radiotherapy versus no active treatment. Over time, more of these men received no active treatment (from 41% to 57%, P<0.001) while fewer received PADT (from 11% to 4%, P<0.001).

CONCLUSION

VA treatment patterns followed evidence-based guidelines against treating older and sicker men with surgery or radiotherapy, for decreasing use of PADT, and for increasingly withholding active treatment, particularly for men with low-risk PCa.

Designing Normative Messages About Active Surveillance for Men With Localized Prostate Cancer

Active surveillance is increasingly recognized as a reasonable option for men with low-risk, localized prostate cancer, yet few men who might benefit from conservative management receive it. The authors examined the acceptability of normative messages about active surveillance as a management option for patients with low-risk prostate cancer. Men with a diagnosis of localized prostate cancer who were recruited through prostate cancer support organizations completed a web-based survey (N = 331). They rated messages about active surveillance for believability, accuracy, and importance for men to hear when making treatment decisions. The message "You don't have to panic … you have time to think about your options" was perceived as believable, accurate, and important by more than 80% of the survivors. In contrast, messages about trust in the active surveillance protocol and "knowing in plenty of time" if treatment is needed were rated as accurate by only about 36% of respondents. For active surveillance to be viewed as a reasonable alternative, men will need reassurance that following an active surveillance protocol is likely to allow time for curative treatment if the cancer progresses.

Accuracy of dose planning for prostate radiotherapy in the presence of metallic implants evaluated by electron spin resonance dosimetry

Radiotherapy is one of the main approaches to cure prostate cancer, and its success depends on the accuracy of dose planning. A complicating factor is the presence of a metallic prosthesis in the femur and pelvis, which is becoming more common in elderly populations. The goal of this work was to perform dose measurements to check the accuracy of radiotherapy treatment planning under these complicated conditions. To accomplish this, a scale phantom of an adult pelvic region was used with alanine dosimeters inserted in the prostate region. This phantom was irradiated according to the planned treatment under the following three conditions: with two metallic prostheses in the region of the femur head, with only one prosthesis, and without any prostheses. The combined relative standard uncertainty of dose measurement by electron spin resonance (ESR)/alanine was 5.05%, whereas the combined relative standard uncertainty of the applied dose was 3.35%, resulting in a combined relative standard uncertainty of the whole process of 6.06%. The ESR dosimetry indicated that there was no difference (P>0.05, ANOVA) in dosage between the planned dose and treatments. The results are in the range of the planned dose, within the combined relative uncertainty, demonstrating that the treatment-planning system compensates for the effects caused by the presence of femur and hip metal prostheses.

Wide Variation in the Diffusion of a New Technology: Practice-Based Trends in Intensity-Modulated Radiation Therapy (IMRT) Use in the State of Michigan, With Implications for IMRT Use Nationally

IMRT use grew significantly across the state of Michigan over time, with four-fold variability among centers, which was related to facility characteristics.

Penile rehabilitation after radical prostatectomy: does it work?

CONTEXT

Erectile dysfunction (ED) represents one of the most common long-term side effects in patients with clinically localized prostate cancer (PCa) undergoing nerve-sparing radical prostatectomy (RP).

OBJECTIVE

To analyze the role of penile rehabilitation in the recovery of erectile function (EF) after nerve-sparing RP.

EVIDENCE SYNTHESIS

Penile rehabilitation is defined as the use of any intervention or combination with the goal not only to achieve erections sufficient for satisfactory sexual intercourses, but also to return EF to preoperative levels. The concept of rehabilitation is based on the implementation of protocols aimed at improving oxygenation, preserving endothelial structure, and preventing smooth muscle structural alterations. Nowadays, the most commonly adopted approaches for penile rehabilitation after nerve-sparing RP are represented by the administration of phosphodiesterase type-5 inhibitors (PDE5-Is), intracorporeal injection therapy, vacuum erection devices (VED), and the combination of these therapies. Several basic science studies support the rational for the adoption of penile rehabilitation protocols. Particularly, rehabilitation, set as early as possible, seems to be better than leaving the erectile tissues unassisted. On the other hand, results from solid prospective randomized trials finally assessing the long-term beneficial effects of PDE5-Is, intracavernosal injections, or VED on EF recovery after surgery are still lacking.

CONCLUSIONS

Although preclinical evidences support the rationale for penile rehabilitation after nerve-sparing RP, clinical studies reported conflicting results regarding its efficacy on long-term EF recovery. Nowadays, which is the optimal rehabilitation program still represents a matter of debate.

Trends and outcome from radical therapy for primary non-metastatic prostate cancer in a UK population

Background

Increasing proportions of men diagnosed with prostate cancer in the UK are presenting with non-metastatic disease. We investigated how treatment trends in this demographic have changed.

Patient and Methods

Non-metastatic cancers diagnosed from 2000–2010 in the UK Anglian Cancer network stratified by age and risk group were analysed [n = 10,365]. Radiotherapy [RT] and prostatectomy [RP] cancer specific survival [CSS] were further compared [n = 4755].

Results

Over the decade we observed a fall in uptake of primary androgen deprivation therapy but a rise in conservative management [CM] and radical therapy [p<0.0001]. CM in particular has become the primary management for low-risk disease by the decade end [p<0.0001]. In high-risk disease however both RP and RT uptake increased significantly but in an age dependent manner [p<0.0001]. Principally, increased RP in younger men and increased RT in men ≥ 70y. In multivariate analysis of radically treated men both high-risk disease [HR 8.0 [2.9–22.2], p<0.0001] and use of RT [HR 1.9 [1.0–3.3], p = 0.024] were significant predictors of a poorer CSM. In age-stratified analysis however, the trend to benefit of RP over RT was seen only in younger men [≤ 60 years] with high-risk disease [p = 0.07]. The numbers needed to treat by RP instead of RT to save one cancer death was 19 for this group but 67 for the overall cohort.

Conclusion

This study has identified significant shifts in non-metastatic prostate cancer management over the last decade. Low-risk disease is now primarily managed by CM while high-risk disease is increasingly treated radically. Treatment of high-risk younger men by RP is supported by evidence of better CSM but this benefit is not evident in older men.

Comparative effectiveness research in urologic cancers

Controversies abound in urologic cancers. While some work in comparative effectiveness research has been performed, most controversies remain unresolved. In this chapter, we examine the three most common urologic malignancies: Prostate cancer, kidney cancer, and bladder cancer. We will review progress made in comparative effectiveness research for each cancer and outline important topics where future research is needed.

Robotic surgery in urological oncology: patient care or market share?

Surgical robotic use has grown exponentially in spite of limited or uncertain benefits and large costs. In certain situations, adoption of robotic technology provides value to patients and society. In other cases, however, the robot provides little or no increase in surgical quality, with increased expense, and, therefore, does not add value to health care. The surgical robot is expensive to purchase, maintain and operate, and can contribute to increased consumerism in relation to surgical procedures, and increased reliance on the technology, thus driving future increases in health-care expenditure. Given the current need for budget constraints, the cost-effectiveness of specific procedures must be evaluated. The surgical robot should be used when cost-effective, but traditional open and laparoscopic techniques also need to be continually fostered.

American trends in expectant management utilization for prostate cancer from 2000 to 2009

INTRODUCTON

The overtreatment of early prostate cancer has become a major public health concern. Expectant management (EM) is a strategy to minimize overtreatment, but little is known about its pattern of use. We sought to examine national EM utilization over the preceding decade.

METHODS

We examined prostate cancer treatment utilization from 2000 to 2009 using the National Cancer Database. EM use was analyzed in relation to other treatments and by cancer stage, age group, Charlson score, and hospital practice setting.

RESULTS

Overall, 109 997 (8.2%) men were managed initially with EM. EM usage remained stable at 7.6% to 9.5% from 2000 to 2009 with no appreciable increase for low-stage cancers. Usage was only slightly higher in elderly patients and in patients with multiple comorbidities. Veterans Affairs and low-volume hospitals had a much higher and increasing EM rate (range: 18.8%-29.8% and 15.1%-24.2%, respectively), compared to community hospitals, comprehensive cancer centres, and teaching hospitals, which showed no increased adoption. On further analysis, EM use remained high for low-stage cancers at Veterans Affairs and low-volume hospitals (24.0% and 19.1%, respectively), regardless of age or comorbidity, a pattern not shared by other practice settings.

CONCLUSIONS

EM utilization remained low and stable last decade, regardless of disease or patient characteristics. Conversely, Veterans Affairs and low-volume hospitals led the trend in national EM adoption, particularly in men with low-stage cancers and limited life expectancies. The limitations of this dataset preclude any determination of the appropriateness of EM utilization. Nonetheless, further study is needed to identify factors influencing EM adoption to ensure its proper use in the future.

Assessing the overuse of medicines

The use of medicines has increased markedly in many countries over recent years, providing clear evidence of the increasing 'pharmacaeuticalisation' of society. This paper contributes to the sociological analysis of pharmaceuticalisation by starting to explore how we can begin to make judgements as to when and to what extent some medicines are being overused--an important aspect that, rather surprisingly, has not so far been the focus of attention those analysing the process. It considers the World Health Organisation's criteria for the 'rational' use of medicines, pointing to some of the issues they raise. It then develops a typology of over and underuse derived from these criteria. This provides a framework for the discussion of assessing overuse that focuses in particular on the widespread and increasing use of medicines that are not very effective for the conditions for which they are prescribed, and their use where the issue of clinical need is in doubt. Some of the factors that encourage overuse are also considered.

Perioperative outcomes and hospital reimbursement by type of radical prostatectomy: results from a privately insured patient population

BACKGROUND

With the increasing use of robotic surgery in the United States, the comparative effectiveness and differences in reimbursement of minimally invasive radical prostatectomy (MIRP) and open prostatectomy (ORP) in privately insured patients are unknown. Therefore, we sought to assess the differences in perioperative outcomes and hospital reimbursement in a privately insured patient population who were surgically treated for prostate cancer.

METHODS

Using a large private insurance database, we identified 17,610 prostate cancer patients who underwent either MIRP or ORP from 2003 to 2010. The primary outcomes were length of stay (LOS), perioperative complications, 90-day readmissions rates and hospital reimbursement. Multivariable regression analyses were used to evaluate for differences in primary outcomes across surgical approaches.

RESULTS

Overall, 8981 (51.0%) and 8629 (49.0%) surgically treated prostate cancer patients underwent MIRP and ORP, respectively. The proportion of patients undergoing MIRP markedly rose from 11.9% in 2003 to 72.5% in 2010 (P<0.001 for trend). Relative to ORP, MIRP was associated with a shorter median LOS (1.0 day vs 3.0 days; P<0.001) and lower adjusted odds ratio of perioperative complications (OR: 0.82; P<0.001). However, the 90-day readmission rates of MIRP and ORP were similar (OR: 0.99; P=0.76). MIRP provided higher adjusted mean hospital reimbursement compared with ORP (US $19,292 vs. US $17,347; P<0.001).

CONCLUSIONS

Among privately insured patients diagnosed with prostate cancer, robotic surgery rapidly disseminated with over 70% of patients undergoing MIRP by 2009-2010. Although MIRP was associated with shorter LOS and modestly better perioperative outcomes, hospitals received higher reimbursement for MIRP compared with ORP.

Robot-assisted radical prostatectomy: inching toward gold standard

Robot-assisted radical prostatectomy (RARP) offers excellent and lasting oncologic control. Technical refinements in apical dissection, such as the retroapical approach of synchronous urethral transection, and adoption of real-time frozen section analysis of the excised prostate during RARP have substantially reduced positive surgical margin rates, particularly in high-risk disease patients. Furthermore, precision offered by the robotic platform and technical evolution of radical prostatectomy, including enhanced nerve sparing (veil), have led to improved potency and continence outcomes as well as better safety profile in patients undergoing surgical therapy for prostate cancer.

Models of assessment of comparative outcomes of robot-assisted surgery: best evidence regarding the superiority or inferiority of robot-assisted radical prostatectomy

The widespread dissemination of robot-assisted radical prostatectomy (RARP) occurred despite the absence of high-level evidence supporting its safety and efficacy in patients with clinically localized prostate cancer. This study aims at systematically evaluating the models adopted in scientific reports assessing the comparative effectiveness of RARP versus open radical prostatectomy (ORP). Although several retrospective observational studies have assessed the comparative effectiveness of RARP and ORP, currently no published randomized data are available to comprehensively evaluate this issue. Furthermore, well-designed prospective investigations are needed to ultimately assess the benefits of RARP compared with other treatment modalities in patients with clinically localized prostate cancer.

Seventh Joint Meeting of K-J-CaP and CaPSURE: extending the global initiative to improve prostate cancer management

This report summarizes the presentations and discussions that took place at the Seventh Joint Meeting of the Korea–Japan Study Group of Prostate Cancer (K-J-CaP) and the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) held in Seoul, Korea, in September 2013. The original J-CaP and CaPSURE Joint Initiative has now been established since 2007 and since the initial collaboration between research teams in the United States (US) and Japan, the project has expanded to include several other Asian countries. The objective of the initiative is to analyze and compare data for prostate cancer patients in the participating countries, looking at similarities and differences in patient management and outcomes. Until now the focus has been primarily on data generated within J-CaP and CaPSURE, both large-scale, longitudinal, observational databases of prostate cancer patients in Japan and the US, respectively. This year’s meeting was hosted for the first time in Korea which has recently established its own national database–K-CaP–to add to the wealth of data generated by J-CaP and CaPSURE. As a newly-developed database, K-CaP has also provided a valuable ‘template’ for other countries, such as China and Indonesia, planning to establish their own national databases and this will ultimately allow greater opportunities for international data comparisons. A range of topics was discussed at this Seventh Joint Meeting including comparison of outcomes following androgen deprivation therapy or radical prostatectomy in patients with localized prostate cancer, the use of active surveillance as a treatment option and the triggers for intervention when employing this regimen, patient quality of life during treatment, the impact of comorbidities on outcomes, and a comparison of recent outcomes data between J-CaP and CaPSURE. The participants recognized that prostate cancer was now a global disease and therefore major insights into understanding and improving the management of this condition would arise from global interactions such as this joint initiative.

Screening and detection advances in magnetic resonance image-guided prostate biopsy

Multiparametric magnetic resonance imaging (MRI) has provided a method for visualizing prostate cancer. MRI-ultrasonography fusion allows prostate biopsy to be performed quickly, on an outpatient basis, using the transrectal technique. Targeted biopsies are more sensitive for detection of prostate cancer than nontargeted, systematic biopsies and detect more significant prostate cancers and fewer insignificant cancers than conventional biopsies. A negative MRI scan should not defer biopsy. Two groups who will especially benefit from targeted prostate biopsy are men with low-risk lesions in active surveillance and men with increased prostate-specific antigen levels and previous negative conventional biopsies.

Racial disparities in prostate cancer-specific mortality in men with low-risk prostate cancer

BACKGROUND

Men with low-risk prostate cancer (CaP) are considered unlikely to die of CaP and have the option of active surveillance. This study evaluated whether African American (AA) men who present with low-risk disease are at higher risk for death from CaP than white men.

PATIENTS AND METHODS

The authors identified 56,045 men with low-risk CaP (T1-T2a, Gleason score ≤ 6, prostate-specific antigen ≤ 10 ng/mL) diagnosed between 2004 and 2009 using the Surveillance, Epidemiology, and End Results (SEER) database. Fine-Gray competing-risks regression analyses were used to analyze the effect of race on prostate cancer-specific mortality (PCSM) after adjusting for known prognostic and sociodemographic factors in 51,315 men (43,792 white; 7523 AA) with clinical follow-up information available.

RESULTS

After a median follow-up of 46 months, 258 patients (209 [0.48%] white and 49 [0.65%] AA men) died from CaP. Both AA race (adjusted hazard ratio [AHR], 1.45; 95% CI, 1.03-2.05; P = .032) and noncurative management (AHR, 1.49; 95% CI, 1.15-1.95; P = .003) were significantly associated with an increased risk of PCSM. When analyzing only patients who underwent curative treatment, AA race (AHR, 1.62; 95% CI, 1.04-2.53; P = .034) remained significantly associated with increased PCSM.

CONCLUSION

Among men with low-risk prostate cancer, AA race compared with white race was associated with a higher risk of PCSM, raising the possibility that clinicians may need to exercise caution when recommending active surveillance for AA men with low-risk disease. Further studies are needed to ultimately determine whether guidelines for active surveillance should take race into account.

The rise and fall of prostate brachytherapy: use of brachytherapy for the treatment of localized prostate cancer in the National Cancer Data Base

BACKGROUND

Brachytherapy has been shown to be an efficacious and cost-effective treatment among patients with localized prostate cancer. In this study, the authors examined trends in brachytherapy use for localized prostate cancer using a large national cancer registry.

METHODS

In the National Cancer Data Base (NCDB), a total of 1,547,941 patients with localized prostate cancer were identified from 1998 through 2010. Excluding patients with lymph node-positive or metastatic disease, the authors examined primary treatment trends focusing on the use of brachytherapy over time. Patients with available data (2004-2009) were stratified by National Comprehensive Cancer Network risk criteria. Controlling for year of diagnosis and demographic, clinical, and pathologic characteristics, multivariate analyses were performed examining the association between patient characteristics and receipt of brachytherapy.

RESULTS

In the study cohort, brachytherapy use reached a peak of 16.7% in 2002, and then steadily declined to a low of 8% in 2010. Of the 719,789 patients with available data for risk stratification, 41.1%, 35.3%, and 23.6%, respectively, met low, intermediate, and high National Comprehensive Cancer Network risk criteria. After adjustment, patients of increasing age and those with Medicare insurance were more likely to receive brachytherapy. In contrast, patients with intermediate-risk or high-risk disease, Medicaid insurance, increasing comorbidity count, and increasing year of diagnosis were less likely to receive brachytherapy.

CONCLUSIONS

For patients with localized prostate cancer who are treated at National Cancer Data Base institutions, there has been a steady decline in brachytherapy use since 2003. For low-risk patients, the declining use of brachytherapy monotherapy compared with more costly emerging therapies has significant health policy implications.

Comparative effectiveness of robot-assisted and open radical prostatectomy in the postdissemination era

PURPOSE

Given the lack of randomized trials comparing robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP), we sought to re-examine the outcomes of these techniques using a cohort of patients treated in the postdissemination era.

PATIENTS AND METHODS

Overall, data from 5,915 patients with prostate cancer treated with RARP or ORP within the SEER-Medicare linked database diagnosed between October 2008 and December 2009 were abstracted. Postoperative complications, blood transfusions, prolonged length of stay (pLOS), readmission, additional cancer therapies, and costs of care within the first year after surgery were compared between the two surgical approaches. To decrease the effect of unmeasured confounders, instrumental variable analysis was performed. Multivariable logistic regression analyses were then performed.

RESULTS

Overall, 2,439 patients (41.2%) and 3,476 patients (58.8%) underwent ORP and RARP, respectively. In multivariable analyses, patients undergoing RARP had similar odds of overall complications, readmission, and additional cancer therapies compared with patients undergoing ORP. However, RARP was associated with a higher probability of experiencing 30- and 90-day genitourinary and miscellaneous medical complications (all P ≤ .02). Additionally, RARP led to a lower risk of experiencing blood transfusion and of having a pLOS (all P < .001). Finally, first-year reimbursements were greater for patients undergoing RARP compared with ORP (P < .001).

CONCLUSION

RARP and ORP have comparable rates of complications and additional cancer therapies, even in the postdissemination era. Although RARP was associated with lower risk of blood transfusions and a slightly shorter length of stay, these benefits do not translate to a decrease in expenditures.

Specialty bias in treatment recommendations and quality of life among radiation oncologists and urologists for localized prostate cancer

BACKGROUND

Given the importance of physician attitudes about different treatments and the quality of life (QOL) in prostate cancer, we performed a national survey of specialists to assess treatment recommendations and perceptions of treatment-related survival and QOL.

METHODS

We mailed a self-administered survey instrument to a random sample of 1366 specialists in the U.S. Respondents were asked for treatment recommendations and survival that varied by PSA levels and Gleason scores and estimate QOL outcomes. Pearson's chi-square and multivariable regression models were used to test for differences in each outcome.

RESULTS

Response rates were similar for radiation oncologists (52.6%) and urologists (52.3%; P=0.92). Across all risk strata, urologists were more likely to recommend surgery than were radiation oncologists, for conditions ranging from PSA>20 and Gleason score 8-10 (35.2 vs. 0.2%; P<0.001) to PSA 4-10 and Gleason score 7 (87.5 vs. 20.9%; P<0.001). Radiation oncologists were also more likely to recommend radiation therapy relative to urologists (all P<0.001). From low- to high-risk prostate cancer, radiation oncologists and urologists perceived their treatment as being better for improving survival (all P<0.001). Each specialty also viewed their treatment as having less urinary incontinence (all P<0.001).

CONCLUSIONS

Radiation oncologists and urologists both prefer the treatment modalities they offer, perceive them to be more effective and to lead to a better QOL. Patients may be receiving biased information, and a truly informed consent process with shared decision-making may be possible only if they are evaluated by both specialties before deciding upon a treatment course.

Comparative effectiveness of robot-assisted versus open radical prostatectomy cancer control

BACKGROUND

Robot-assisted radical prostatectomy (RARP) remains controversial, and no improvement in cancer control outcomes has been demonstrated over open radical prostatectomy (ORP).

OBJECTIVE

To examine population-based, comparative effectiveness of RARP versus ORP pertaining surgical margin status and use of additional cancer therapy.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective observational study of 5556 RARP and 7878 ORP cases from 2004 to 2009 from Surveillance Epidemiology and End Results-Medicare linked data.

INTERVENTION

RARP versus ORP.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Propensity-based analyses were performed to minimize treatment selection biases. Generalized linear regression models were computed for comparison of RP surgical margin status and use of additional cancer therapy (radiation therapy [RT] or androgen deprivation therapy [ADT]) by surgical approach.

RESULTS AND LIMITATIONS

In the propensity-adjusted analysis, RARP was associated with fewer positive surgical margins (13.6% vs 18.3%; odds ratio [OR]: 0.70; 95% confidence interval [CI], 0.66-0.75), largely because of fewer RARP positive margins for intermediate-risk (15.0% vs 21.0%; OR: 0.66; 95% CI, 0.59-0.75) and high-risk (15.1% vs 20.6%; OR: 0.70; 95% CI, 0.63-0.77) disease. In addition, RARP was associated with less use of additional cancer therapy within 6 mo (4.5% vs 6.2%; OR: 0.75; 95% CI, 0.69-0.81), 12 mo (OR: 0.73; 95% CI, 0.62-0.86), and 24 mo (OR: 0.67; 95% CI, 0.57-0.78) of surgery. Limitations include the retrospective nature of the study and the absence of prostate-specific antigen levels to determine biochemical recurrence.

CONCLUSIONS

RARP is associated with improved surgical margin status relative to ORP for intermediate- and high-risk disease and less use of postprostatectomy ADT and RT. This has important implications for quality of life, health care delivery, and costs.

PATIENT SUMMARY

Robot-assisted radical prostatectomy (RP) versus open RP is associated with fewer positive margins and better early cancer control because of less use of additional androgen deprivation and radiation therapy within 2 yr of surgery.

The impact of technology diffusion on treatment for prostate cancer

BACKGROUND

The use of local therapy for prostate cancer may increase because of the perceived advantages of new technologies such as intensity-modulated radiotherapy (IMRT) and robotic prostatectomy.

OBJECTIVE

To examine the association of market-level technological capacity with receipt of local therapy.

DESIGN

Retrospective cohort.

SUBJECTS

Patients with localized prostate cancer who were diagnosed between 2003 and 2007 (n=59,043) from the Surveillance Epidemiology and End Results-Medicare database.

MEASURES

We measured the capacity for delivering treatment with new technology as the number of providers offering robotic prostatectomy or IMRT per population in a market (hospital referral region). The association of this measure with receipt of prostatectomy, radiotherapy, or observation was examined with multinomial logistic regression.

RESULTS

For each 1000 patients diagnosed with prostate cancer, 174 underwent prostatectomy, 490 radiotherapy, and 336 were observed. Markets with high robotic prostatectomy capacity had higher use of prostatectomy (146 vs. 118 per 1000 men, P=0.008) but a trend toward decreased use of radiotherapy (574 vs. 601 per 1000 men, P=0.068), resulting in a stable rate of local therapy. High versus low IMRT capacity did not significantly impact the use of prostatectomy (129 vs. 129 per 1000 men, P=0.947) and radiotherapy (594 vs. 585 per 1000 men, P=0.579).

CONCLUSIONS

Although there was a small shift from radiotherapy to prostatectomy in markets with high robotic prostatectomy capacity, increased capacity for both robotic prostatectomy and IMRT did not change the overall rate of local therapy. Our findings temper concerns that the new technology spurs additional therapy of prostate cancer.

Secondary data analysis of large data sets in urology: successes and errors to avoid

PURPOSE

Secondary data analysis is the use of data collected for research by someone other than the investigator. In the last several years there has been a dramatic increase in the number of these studies being published in urological journals and presented at urological meetings, especially involving secondary data analysis of large administrative data sets. Along with this expansion, skepticism for secondary data analysis studies has increased for many urologists.

MATERIALS AND METHODS

In this narrative review we discuss the types of large data sets that are commonly used for secondary data analysis in urology, and discuss the advantages and disadvantages of secondary data analysis. A literature search was performed to identify urological secondary data analysis studies published since 2008 using commonly used large data sets, and examples of high quality studies published in high impact journals are given. We outline an approach for performing a successful hypothesis or goal driven secondary data analysis study and highlight common errors to avoid.

RESULTS

More than 350 secondary data analysis studies using large data sets have been published on urological topics since 2008 with likely many more studies presented at meetings but never published. Nonhypothesis or goal driven studies have likely constituted some of these studies and have probably contributed to the increased skepticism of this type of research. However, many high quality, hypothesis driven studies addressing research questions that would have been difficult to conduct with other methods have been performed in the last few years.

CONCLUSIONS

Secondary data analysis is a powerful tool that can address questions which could not be adequately studied by another method. Knowledge of the limitations of secondary data analysis and of the data sets used is critical for a successful study. There are also important errors to avoid when planning and performing a secondary data analysis study. Investigators and the urological community need to strive to use secondary data analysis of large data sets appropriately to produce high quality studies that hopefully lead to improved patient outcomes.