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Paudel R, Ferrante S, Woodford J, Maitland C, Stockall E, Maatman T, Lane GI, Berry DL, Sales AE, Montie JE. Implementation of prostate cancer treatment decision aid in Michigan: a qualitative study. Implement Sci Commun 2021; 2:27. [PMID: 33676583 PMCID: PMC7936475 DOI: 10.1186/s43058-021-00125-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 02/05/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The American Urological Association White Paper on Implementation of Shared Decision Making (SDM) into Urological Practice suggested SDM represents the state of the art in counseling for patients who are faced with difficult or uncertain medical decisions. The Michigan Urological Surgery Improvement Collaborative (MUSIC) implemented a decision aid, Personal Patient Profile-Prostate (P3P), in 2018 to help newly diagnosed prostate cancer patients make shared decisions with their clinicians. We conducted a qualitative study to assess statewide implementation of P3P throughout MUSIC. METHODS We recruited urologists and staff from 17 MUSIC practices (8 implementation and 9 comparator practices) to understand how practices engaged patients on treatment discussions and to assess facilitators and barriers to implementing P3P. Interview guides were developed based on the Tailored Interventions for Chronic Disease (TICD) Framework. Interviews were transcribed for analysis and coded independently by two investigators in NVivo, PRO 12. Additionally, quantitative program data were integrated into thematic analyses. RESULTS We interviewed 15 urologists and 11 staff from 16 practices. Thematic analysis of interview transcripts indicated three key themes including the following: (i) P3P is compatible as a SDM tool as over 80% of implementation urologists asked patients to complete the P3P questionnaire routinely and used P3P reports during treatment discussions; (ii) patient receptivity was demonstrated by 370 (50%) of newly diagnosed patients (n = 737) from 8 practices enrolled in P3P with 78% completion rate, which accounts for 39% of all newly diagnosed patients in these practices; and (iii) urologists' attitudes towards SDM varied. Over a third of urologists stated they did not rely on a decision aid. Comparator practices indicated habit, inertia, or concerns about clinic flow as reasons for not adopting P3P and some were unconvinced a decision aid is needed in their practice. CONCLUSION Urologists and staff affiliated with MUSIC implementation sites indicated that P3P focuses the treatment discussion on items that are important to patients. Experiences of implementation practices indicate that once initiated, there were no negative effects on clinic flow and urologists indicated P3P saves time during patient counseling, as patients were better prepared for focused discussions. Lack of awareness, personal habits, and inertia are reasons for not implementing P3P among the comparator practices.
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Affiliation(s)
- Roshan Paudel
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI USA
| | - Stephanie Ferrante
- Michigan Urological Surgery Improvement Collaborative, University of Michigan, Ann Arbor, MI USA
| | | | | | | | | | - Giulia I. Lane
- Department of Urology, University of Michigan, Ann Arbor, MI USA
| | - Donna L. Berry
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA USA
| | - Anne E. Sales
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI USA
| | - James E. Montie
- Michigan Urological Surgery Improvement Collaborative, University of Michigan, Ann Arbor, MI USA
| | - for the Michigan Urological Surgery Improvement Collaborative (MUSIC), Ann Arbor, Michigan, USA
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI USA
- Michigan Urological Surgery Improvement Collaborative, University of Michigan, Ann Arbor, MI USA
- University of Michigan, Ann Arbor, MI USA
- Sherwood Medical Center, Detroit, MI USA
- Capital Urological Associates, Okemos, MI USA
- Michigan Urological Clinic, Grand Rapids, MI USA
- Department of Urology, University of Michigan, Ann Arbor, MI USA
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA USA
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Therapeutic Consequences of Omitting a Pelvic Lymph Node Dissection at Radical Prostatectomy when Grade and/or Stage Increase. Urology 2021; 155:144-151. [PMID: 33676955 DOI: 10.1016/j.urology.2021.01.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/22/2020] [Accepted: 01/07/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To analyze the effect on biochemical recurrence (BCR) of omitting PLND in subsequently upgraded/upstaged patients (pNx regret). Using nomograms, patients with low to intermediate-risk prostate cancer can be selected to omit a pelvic lymph node dissection (PLND) at the time of a radical prostatectomy (RP). However, some patients will experience upgraded pathology and/or stage. MATERIALS AND METHODS We searched a prospectively maintained single institution/multi-surgeon cohort of patients treated by RP and >5-year follow-up. From 2006-2012, 1026 (521 pNx and 505 pN0/1) eligible patients with biopsy Gleason Score ≤3+4 and cT1c-cT2 undergoing RARP were included in the study. RESULTS Gleason upgrading from ≤3+4 to >3+4 and/or pT3-4 occurred in 17% of pNx and 32% of pN0/N1 (p<0.001). BCR occurred in 5% of the pNx, and 7% of the PLND group. Five-year BCR free survival was higher in the pNx group (94.7% vs. 91%, P = .048). BCR occurred in 3% in the non-pNx regret and 18% in the pNx regret patients. However, with propensity score matching with pNx regret and pN0/N1 patients, 5-year BCR free survival rates were similar (81% vs 77%, P = .466). CONCLUSIONS Low to favorable intermediate-risk patients who PLND was omitted and experienced upgrading or upstaging (pNx regret), have a higher predicted BCR. However, when matched to a similar cohort with pN0/N1, the BCR did not differ. Omission of a PLND does not appear to alter the rates of BCR compared to PLND inclusion.
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303
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Tan WP, Rastinehad AR, Klotz L, Carroll PR, Emberton M, Feller JF, George AK, Gill IS, Gupta RT, Katz AE, Lebastchi AH, Marks LS, Marra G, Pinto PA, Song DY, Sidana A, Ward JF, Sanchez-Salas R, Rosette JDL, Polascik TJ. Utilization of focal therapy for patients discontinuing active surveillance of prostate cancer: Recommendations of an international Delphi consensus. Urol Oncol 2021; 39:781.e17-781.e24. [PMID: 33676851 DOI: 10.1016/j.urolonc.2021.01.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/19/2021] [Accepted: 01/25/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND With the advancement of imaging technology, focal therapy (FT) has been gaining acceptance for the treatment of select patients with localized prostate cancer (CaP). We aim to provide details of a formal physician consensus on the utilization of FT for patients with CaP who are discontinuing active surveillance (AS). METHODS A 3-stage Delphi consensus on CaP and FT was conducted. Consensus was defined as agreement by ≥80% of physicians. An in-person meeting was attended by 17 panelists to formulate the consensus statement. RESULTS Fifty-six respondents participated in this interdisciplinary consensus study (82% urologist, 16% radiologist, 2% radiation oncology). The participants confirmed that there is a role for FT in men discontinuing AS (48% strongly agree, 39% agree). The benefit of FT over radical therapy for men coming off AS is: less invasive (91%), has a greater likelihood to preserve erectile function (91%), has a greater likelihood to preserve urinary continence (91%), has fewer side effects (86%), and has early recovery post-treatment (80%). Patients will need to undergo mpMRI of the prostate and/or a saturation biopsy to determine if they are potential candidates for FT. Our limitations include respondent's biases and that the participants of this consensus may not represent the larger medical community. CONCLUSIONS FT can be offered to men coming off AS between the age of 60 to 80 with grade group 2 localized cancer. This consensus from a multidisciplinary, multi-institutional, international expert panel provides a contemporary insight utilizing FT for CaP in select patients who are discontinuing AS.
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Affiliation(s)
- Wei Phin Tan
- Division of Urology, Duke University Medical Center, Durham, NC
| | | | - Laurence Klotz
- Department of Urology, University of Toronto, Toronto, Ontario
| | - Peter R Carroll
- Department of Urology, University of California San Francisco, San Francisco, CA
| | - Mark Emberton
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | | | - Arvin K George
- Department of Urology, University of Michigan, Ann Arbor, MI
| | - Inderbir S Gill
- Department of Urology, University of Southern California, Los Angeles, CA
| | - Rajan T Gupta
- Department of Radiology, Duke University Medical Center, Durham, NC
| | - Aaron E Katz
- Department of Urology, New York University, New York City, NY
| | - Amir H Lebastchi
- Department of Urology, University of Southern California, Los Angeles, CA
| | - Leonard S Marks
- Department of Urology, University of California Los Angeles, Los Angeles, CA
| | | | - Peter A Pinto
- Urologic Oncology Branch of the National Cancer Institute, Bethesda, MD
| | - Daniel Y Song
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD
| | - Abhinav Sidana
- Department of Urology, University of Cincinnati, Cincinnati, OH
| | - John F Ward
- Department of Urology, MD Anderson Cancer Center, Houston, TX
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Nair-Shalliker V, Smith DP, Gebski V, Patel MI, Frydenberg M, Yaxley JW, Gardiner R, Espinoza D, Kimlin MG, Fenech M, Gillatt D, Woo H, Armstrong BK, Rasiah K, Awad N, Symons J, Gurney H. High-dose vitamin D supplementation to prevent prostate cancer progression in localised cases with low-to-intermediate risk of progression on active surveillance (ProsD): protocol of a phase II randomised controlled trial. BMJ Open 2021; 11:e044055. [PMID: 33653757 PMCID: PMC7929872 DOI: 10.1136/bmjopen-2020-044055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
INTRODUCTION Active surveillance (AS) for patients with prostate cancer (PC) with low risk of PC death is an alternative to radical treatment. A major drawback of AS is the uncertainty whether a patient truly has low risk PC based on biopsy alone. Multiparametric MRI scan together with biopsy, appears useful in separating patients who need curative therapy from those for whom AS may be safe. Two small clinical trials have shown short-term high-dose vitamin D supplementation may prevent PC progression. There is no substantial evidence for its long-term safety and efficacy, hence its use in the care of men with PC on AS needs assessment. This protocol describes the ProsD clinical trial which aims to determine if oral high-dose vitamin D supplementation taken monthly for 2 years can prevent PC progression in cases with low-to-intermediate risk of progression. METHOD AND ANALYSIS This is an Australian national multicentre, 2:1 double-blinded placebo-controlled phase II randomised controlled trial of monthly oral high-dose vitamin D supplementation (50 000 IU cholecalciferol), in men diagnosed with localised PC who have low-to-intermediate risk of disease progression and are being managed by AS. This trial will assess the feasibility, efficacy and safety of supplementing men with an initial oral loading dose of 500 000 IU cholecalciferol, followed by a monthly oral dose of 50 000 IU during the 24 months of AS. The primary trial outcome is the commencement of active therapy for clinical or non-clinical reason, within 2 years of AS. ETHICS AND DISSEMINATION This trial is approved by Bellberry Ethics Committee (2016-06-459). All results will be reported in peer-reviewed journals. TRIAL REGISTRATION NUMBER ACTRN12616001707459.
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Affiliation(s)
- Visalini Nair-Shalliker
- Cancer Research Division, Cancer Council New South Wales, Woolloomooloo, New South Wales, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - David P Smith
- Cancer Research Division, Cancer Council New South Wales, Woolloomooloo, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Val Gebski
- Clinical Trials Center, The University of Sydney, Sydney, New South Wales, Australia
| | - Manish I Patel
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Discipline of Surgery, The University of Sydney, Sydney, New South Wales, Australia
| | | | - John W Yaxley
- Centre for Clinical Research, The University of Queensland, Saint Lucia, Queensland, Australia
- Wesley Urology Clinic, Wesley Hospital, Brisbane, Queensland, Australia
| | - Robert Gardiner
- Centre for Clinical Research, The University of Queensland, Saint Lucia, Queensland, Australia
| | - David Espinoza
- Clinical Trials Center, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael G Kimlin
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Michael Fenech
- Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - David Gillatt
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Henry Woo
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Adventist Hospital Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Bruce K Armstrong
- School of Public Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Krishan Rasiah
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Urology, North Shore Private Hospital, St Leonards, New South Wales, Australia
| | - Nader Awad
- Urology Centre, Port Macquarie, New South Wales, Australia
- Rural Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - James Symons
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Adventist Hospital Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Howard Gurney
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
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305
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MORI K, MIURA N, COMPERAT E, NIKLES S, PANG KH, MISRAI V, GOMEZ RIVAS J, PAPALIA R, SHARIAT SF, ESPERTO F, PRADERE B. A systematic review and meta-analysis of prognostic impact of different Gleason patterns in ISUP grade group 4. Minerva Urol Nephrol 2021; 73:42-49. [DOI: 10.23736/s2724-6051.20.03778-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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306
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Pyrgidis N, Vakalopoulos I, Sountoulides P. Endocrine consequences of treatment with the new androgen receptor axis-targeted agents for advanced prostate cancer. Hormones (Athens) 2021; 20:73-84. [PMID: 33140306 DOI: 10.1007/s42000-020-00251-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/08/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Prostate cancer (PCa) is the commonest non-cutaneous malignancy worldwide and the second cause of cancer death among males in the USA. Approval of the new androgen receptor axis-targeted (ARAT) agents (abiraterone acetate, enzalutamide, apalutamide, and darolutamide) has altered the course of advanced PCa. We aimed to assess the endocrine and metabolic adverse events associated with treatment using ARAT compounds. METHODS We searched the PubMed, Cochrane Library, and Scopus databases from database inception to August 2020. We included randomized controlled trials reporting the endocrine and metabolic side effects of ARAT agents compared to each other or to placebo. RESULTS Although metastatic PCa remains incurable, ARAT medications combined with androgen deprivation therapy improve overall metastasis-free and progression-free survival in metastatic hormone-sensitive PCa, non-metastatic castration-resistant PCa, and metastatic castration-resistant PCa patients. This benefit comes at the cost of certain endocrine and metabolic consequences. Treatment with abiraterone acetate induces mineralocorticoid excess, hypokalemia, hypertension, elevated liver function tests, insulin resistance, and hyperglycemia. Enzalutamide may induce or worsen hypertension and increase the risk of falls and fractures in elderly patients, while common endocrine adverse events of apalutamide include hypothyroidism, hypertension, and skin rash. On the other hand, darolutamide seems to have a somewhat safer endocrine and metabolic profile. CONCLUSION Treatment of advanced PCa should be personalized, with administration of a combination of androgen deprivation therapy, ARAT agents, and chemotherapy being based on the patient's safety profile and the risk of side effects.
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Affiliation(s)
- Nikolaos Pyrgidis
- 1st Department of Urology, Aristotle University of Thessaloniki, 15-17 Agiou Evgeniou Street, TK 55133, Thessaloniki, Greece
| | - Ioannis Vakalopoulos
- 1st Department of Urology, Aristotle University of Thessaloniki, 15-17 Agiou Evgeniou Street, TK 55133, Thessaloniki, Greece
| | - Petros Sountoulides
- 1st Department of Urology, Aristotle University of Thessaloniki, 15-17 Agiou Evgeniou Street, TK 55133, Thessaloniki, Greece.
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307
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Armstrong N, Quek RGW, Ryder S, Ross J, Buksnys T, Forbes C, Fox KM, Castro E. DNA damage repair gene mutation testing and genetic counseling in men with/without prostate cancer: a systematic review. Future Oncol 2021; 17:853-864. [DOI: 10.2217/fon-2020-0569] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Ongoing clinical trials are investigating PARP inhibitors to target the DNA damage repair (DDR) pathway in prostate cancer. DDR mutation screening will guide treatment strategy and assess eligibility for clinical trials. Materials & methods: This systematic review estimated the rate of DDR mutation testing or genetic counseling among men with or at risk of prostate cancer. Results: From 6856 records, one study fulfilled the inclusion criteria and described men undiagnosed with prostate cancer with a family history of BRCA1/2 mutation who received DDR mutation testing. Conclusion: With only one study included in this first systematic review of DDR mutation testing or genetic counseling in men with or at risk of prostate cancer, more research is warranted.
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Affiliation(s)
| | | | | | | | | | | | - Kathleen M Fox
- Strategic Healthcare Solutions, LLC, Aiken, SC 29803, USA
| | - Elena Castro
- Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA), Spain
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308
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Shapiro DD, Ward JF, Lim AH, Nogueras-González GM, Chapin BF, Davis JW, Gregg JR, Chapin BF, Davis JW, Ward JF. Comparing confirmatory biopsy outcomes between MRI-targeted biopsy and standard systematic biopsy among men being enrolled in prostate cancer active surveillance. BJU Int 2021; 127:340-348. [PMID: 32357283 PMCID: PMC9798524 DOI: 10.1111/bju.15100] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To evaluate the ability of magnetic resonance imaging (MRI)-targeted biopsy combined with systematic biopsy (MRI-biopsy) to reduce negative biopsies and detect clinically significant prostate cancer compared to systematic biopsy (SB) alone in the confirmatory biopsy setting using matched cohorts. PATIENTS AND METHODS Patients were identified from an active surveillance database who had a previously positive transrectal ultrasonography-guided SB followed by a confirmatory biopsy at a single institution between 2006 and 2019. Patients were divided into two cohorts based on confirmatory biopsy technique: SB alone or MRI-biopsy (which included MRI-targeted and systematic biopsies). Cohorts were then matched on age, prostate-specific antigen (PSA) level, number of positive cores on initial biopsy and initial biopsy Gleason grade group (GG). Logistic regression was performed to identify associations with confirmatory biopsy upgrading. RESULTS After matching, 514 patients were identified (257 per cohort). PSA, prostate volume and PSA density prior to initial biopsy, in addition to total number of initial biopsy positive cores and GG, were similar between the matched cohorts. After confirmatory biopsy, 118/257 patients (45.9%) in the MRI-biopsy cohort were upgraded compared to 46/257 patients (17.9%) in the SB cohort (P < 0.001). The rate of negative confirmatory biopsy was 32/257 (12.5%) compared to 97/257 (37.7%) in the MRI-biopsy and SB cohorts, respectively (P < 0.001). Confirmatory MRI-biopsy was associated with greater odds of confirmatory biopsy upgrade from GG 1 to ≥GG 2 compared to SB alone (odds ratio 3.62, 95% confidence interval 1.97-6.63; P < 0.001). CONCLUSION The addition of MRI-targeted biopsies to SB in the confirmatory biopsy setting among men with previously detected prostate cancer resulted in fewer negative confirmatory biopsies and detection of more clinically significant prostate cancer compared to SB alone.
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Affiliation(s)
- Daniel D. Shapiro
- Department of Urology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX
| | - John F. Ward
- Department of Urology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX
| | - Amy H. Lim
- Department of Urology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX
| | | | - Brian F. Chapin
- Department of Urology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX
| | - John W. Davis
- Department of Urology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX
| | - Justin R. Gregg
- Department of Urology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX
| | - Brian F Chapin
- Department of Urology, Anderson Cancer Centre, University of Texas, M.D., Houston, TX, USA
| | - John W Davis
- Department of Urology, Anderson Cancer Centre, University of Texas, M.D., Houston, TX, USA
| | - John F Ward
- Department of Urology, Anderson Cancer Centre, University of Texas, M.D., Houston, TX, USA
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309
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High-Risk Prostate Cancer: A Very Challenging Disease in the Field of Uro-Oncology. Diagnostics (Basel) 2021; 11:diagnostics11030400. [PMID: 33652852 PMCID: PMC7996958 DOI: 10.3390/diagnostics11030400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Prostate cancer (PCa) is the most common cancer in males and affects 16% of men during their lifetime [...].
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310
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Dall'Era M. Liquid biomarkers in active surveillance. World J Urol 2021; 40:21-26. [PMID: 33590279 DOI: 10.1007/s00345-021-03609-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/25/2021] [Indexed: 10/22/2022] Open
Abstract
PURPOSE In the past two decades, new biomarkers for prostate cancer detection and risk prediction have become available for clinical use. While tissue-based gene expression assays offer molecular risk assessment after diagnoses, several serum- and urine-based 'liquid' biomarkers are available for the pre-biopsy setting which may also play a role for active surveillance (AS). METHODS The medical literature was queried utilizing PubMed (pubmed.ncbi.nlm.nih.gov) for all relevant original publications describing prostate cancer biomarkers that can be identified in the blood, urine, or semen. Referenced studies must have defined patient inclusion criteria and descriptions of the biomarkers. Included studies investigated the utility of liquid biomarkers for selection or monitoring of men with prostate cancer for active surveillance. RESULTS PSA is the most common and readily available biomarker for prostate cancer diagnosis and treatment. Contemporary AS guidelines consider diagnostic PSA level in addition to other clinical factors when selecting men for this approach, with most recommending that initial PSA should be under 10 ng/ml. Serum PSA changes are associated with outcomes on AS but are not adequately sensitive so drive men to secondary treatment in isolation. PSA derivates including the Prostate Health Index (phi) and the 4K Score can predict higher grade cancer and may help tailor repeat prostate biopsy strategies, but further data are needed prior to routine clinic use. Several urine-based biomarkers including PCA3 and TMPRSS2:ERG levels have also been studied in the AS setting. CONCLUSIONS Multiple serum- and urine-based liquid biomarkers are available for use in men with prostate cancer. For AS, serum PSA is utilized in part for patient selection as well as to monitor disease over time. Models that incorporate PSA kinetics with other clinical characteristics may help tailor surveillance strategies to reduce disease burden and health care costs over time. Several novel liquid biomarkers demonstrate promise and may eventually have applications for prostate cancer surveillance as well.
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Affiliation(s)
- Marc Dall'Era
- Department of Urologic Surgery, University of California Davis Comprehensive Cancer Center, 4860 Y Street, Suite 3500, Sacramento, CA, 95864, USA.
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311
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Zhang L, Zhao H, Wu B, Zha Z, Yuan J, Feng Y. The Impact of Neoadjuvant Hormone Therapy on Surgical and Oncological Outcomes for Patients With Prostate Cancer Before Radical Prostatectomy: A Systematic Review and Meta-Analysis. Front Oncol 2021; 10:615801. [PMID: 33628732 PMCID: PMC7897693 DOI: 10.3389/fonc.2020.615801] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/14/2020] [Indexed: 01/07/2023] Open
Abstract
Objective This systematic study aimed to assess and compare the comprehensive evidence regarding the impact of neoadjuvant hormone therapy (NHT) on surgical and oncological outcomes of patients with prostate cancer (PCa) before radical prostatectomy (RP). Methods Literature searches were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Using PubMed, Web of Science, Chinese National Knowledge Infrastructure, and Wanfang databases, we identified relevant studies published before July 2020. The pooled effect sizes were calculated in terms of the odds ratios (ORs)/standard mean differences (SMDs) with 95% confidence intervals (CIs) using the fixed or random-effects model. Results We identified 22 clinical trials (6 randomized and 16 cohort) including 20,199 patients with PCa. Our meta-analysis showed no significant differences in body mass index (SMD = 0.10, 95% CI: -0.08-0.29, p = 0.274) and biopsy Gleason score (GS) (OR = 1.33, 95% CI: 0.76-2.35 p = 0.321) between the two groups. However, the NHT group had a higher mean age (SMD = 0.19, 95% CI: 0.07-0.31, p = 0.001), preoperative prostate-specific antigen (OR = 0.47, 95% CI: 0.19-0.75, p = 0.001), and clinic tumor stage (OR = 2.24, 95% CI: 1.53-3.29, p < 0.001). Compared to the RP group, the NHT group had lower positive surgical margins (PSMs) rate (OR = 0.44, 95% CI: 0.29-0.67, p < 0.001) and biochemical recurrence (BCR) rate (OR = 0.47, 95% CI: 0.26-0.83, p = 0.009). Between both groups, there were no significant differences in estimated blood loss (SMD = -0.06, 95% CI: -0.24-0.13, p = 0.556), operation time (SMD = 0.20, 95% CI: -0.12-0.51, p = 0.219), pathological tumor stage (OR = 0.76, 95% CI: 0.54-1.06, p = 0.104), specimen GS (OR = 0.91, 95% CI: 0.49-1.68, p = 0.756), and lymph node involvement (OR = 0.76, 95% CI: 0.40-1.45, p = 0.404). Conclusions NHT prior to RP appeared to reduce the tumor stage, PSMs rate, and risk of BCR in patients with PCa. According to our data, NHT may be more suitable for older patients with higher tumor stage. Besides, NHT may not increase the surgical difficulty of RP.
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Affiliation(s)
- Lijin Zhang
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, Jiang-yin, China
| | - Hu Zhao
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, Jiang-yin, China
| | - Bin Wu
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, Jiang-yin, China
| | - Zhenlei Zha
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, Jiang-yin, China
| | - Jun Yuan
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, Jiang-yin, China
| | - Yejun Feng
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, Jiang-yin, China
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312
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Carlsson S, Ehdaie B, Vickers A. What is a good medical choice? Cancer 2021; 127:1933-1934. [PMID: 33544415 DOI: 10.1002/cncr.33447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/16/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Sigrid Carlsson
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Behfar Ehdaie
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Andrew Vickers
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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313
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Xie J, Li B, Min X, Zhang P, Fan C, Li Q, Wang L. Prediction of Pathological Upgrading at Radical Prostatectomy in Prostate Cancer Eligible for Active Surveillance: A Texture Features and Machine Learning-Based Analysis of Apparent Diffusion Coefficient Maps. Front Oncol 2021; 10:604266. [PMID: 33614487 PMCID: PMC7890009 DOI: 10.3389/fonc.2020.604266] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/18/2020] [Indexed: 12/09/2022] Open
Abstract
Objective To evaluate a combination of texture features and machine learning-based analysis of apparent diffusion coefficient (ADC) maps for the prediction of Grade Group (GG) upgrading in Gleason score (GS) ≤6 prostate cancer (PCa) (GG1) and GS 3 + 4 PCa (GG2). Materials and methods Fifty-nine patients who were biopsy-proven to have GG1 or GG2 and underwent MRI examination with the same MRI scanner prior to transrectal ultrasound (TRUS)-guided systemic biopsy were included. All these patients received radical prostatectomy to confirm the final GG. Patients were divided into training cohort and test cohort. 94 texture features were extracted from ADC maps for each patient. The independent sample t-test or Mann−Whitney U test was used to identify the texture features with statistically significant differences between GG upgrading group and GG non-upgrading group. Texture features of GG1 and GG2 were compared based on the final pathology of radical prostatectomy. We used the least absolute shrinkage and selection operator (LASSO) algorithm to filter features. Four supervised machine learning methods were employed. The prediction performance of each model was evaluated by area under the receiver operating characteristic curve (AUC). The statistical comparison between AUCs was performed. Results Six texture features were selected for the machine learning models building. These texture features were significantly different between GG upgrading group and GG non-upgrading group (P < 0.05). The six features had no significant difference between GG1 and GG2 based on the final pathology of radical prostatectomy. All machine learning methods had satisfactory predictive efficacy. The diagnostic performance of nearest neighbor algorithm (NNA) and support vector machine (SVM) was better than random forests (RF) in the training cohort. The AUC, sensitivity, and specificity of NNA were 0.872 (95% CI: 0.750−0.994), 0.967, and 0.778, respectively. The AUC, sensitivity, and specificity of SVM were 0.861 (95%CI: 0.732−0.991), 1.000, and 0.722, respectively. There had no significant difference between AUCs in the test cohort. Conclusion A combination of texture features and machine learning-based analysis of ADC maps could predict PCa GG upgrading from biopsy to radical prostatectomy non-invasively with satisfactory predictive efficacy.
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Affiliation(s)
- Jinke Xie
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Basen Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiangde Min
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peipei Zhang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chanyuan Fan
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiubai Li
- Department of Radiology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, United States
| | - Liang Wang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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314
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Henning GM, Kim EH. Predicting prostate cancer-specific mortality using SEER. LANCET DIGITAL HEALTH 2021; 3:e138-e139. [PMID: 33549514 DOI: 10.1016/s2589-7500(21)00020-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/24/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Grant M Henning
- Department of Surgery, Washington University School of Medicine, St Louis, MO 63110, USA
| | - Eric H Kim
- Department of Surgery, Washington University School of Medicine, St Louis, MO 63110, USA.
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315
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Lee C, Light A, Alaa A, Thurtle D, van der Schaar M, Gnanapragasam VJ. Application of a novel machine learning framework for predicting non-metastatic prostate cancer-specific mortality in men using the Surveillance, Epidemiology, and End Results (SEER) database. LANCET DIGITAL HEALTH 2021; 3:e158-e165. [PMID: 33549512 DOI: 10.1016/s2589-7500(20)30314-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/03/2020] [Accepted: 12/10/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Accurate prognostication is crucial in treatment decisions made for men diagnosed with non-metastatic prostate cancer. Current models rely on prespecified variables, which limits their performance. We aimed to investigate a novel machine learning approach to develop an improved prognostic model for predicting 10-year prostate cancer-specific mortality and compare its performance with existing validated models. METHODS We derived and tested a machine learning-based model using Survival Quilts, an algorithm that automatically selects and tunes ensembles of survival models using clinicopathological variables. Our study involved a US population-based cohort of 171 942 men diagnosed with non-metastatic prostate cancer between Jan 1, 2000, and Dec 31, 2016, from the prospectively maintained Surveillance, Epidemiology, and End Results (SEER) Program. The primary outcome was prediction of 10-year prostate cancer-specific mortality. Model discrimination was assessed using the concordance index (c-index), and calibration was assessed using Brier scores. The Survival Quilts model was compared with nine other prognostic models in clinical use, and decision curve analysis was done. FINDINGS 647 151 men with prostate cancer were enrolled into the SEER database, of whom 171 942 were included in this study. Discrimination improved with greater granularity, and multivariable models outperformed tier-based models. The Survival Quilts model showed good discrimination (c-index 0·829, 95% CI 0·820-0·838) for 10-year prostate cancer-specific mortality, which was similar to the top-ranked multivariable models: PREDICT Prostate (0·820, 0·811-0·829) and Memorial Sloan Kettering Cancer Center (MSKCC) nomogram (0·787, 0·776-0·798). All three multivariable models showed good calibration with low Brier scores (Survival Quilts 0·036, 95% CI 0·035-0·037; PREDICT Prostate 0·036, 0·035-0·037; MSKCC 0·037, 0·035-0·039). Of the tier-based systems, the Cancer of the Prostate Risk Assessment model (c-index 0·782, 95% CI 0·771-0·793) and Cambridge Prognostic Groups model (0·779, 0·767-0·791) showed higher discrimination for predicting 10-year prostate cancer-specific mortality. c-indices for models from the National Comprehensive Cancer Care Network, Genitourinary Radiation Oncologists of Canada, American Urological Association, European Association of Urology, and National Institute for Health and Care Excellence ranged from 0·711 (0·701-0·721) to 0·761 (0·750-0·772). Discrimination for the Survival Quilts model was maintained when stratified by age and ethnicity. Decision curve analysis showed an incremental net benefit from the Survival Quilts model compared with the MSKCC and PREDICT Prostate models currently used in practice. INTERPRETATION A novel machine learning-based approach produced a prognostic model, Survival Quilts, with discrimination for 10-year prostate cancer-specific mortality similar to the top-ranked prognostic models, using only standard clinicopathological variables. Future integration of additional data will likely improve model performance and accuracy for personalised prognostics. FUNDING None.
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Affiliation(s)
- Changhee Lee
- Department of Electrical and Computer Engineering, University of California, Los Angeles, CA, USA
| | - Alexander Light
- Department of Surgery, Division of Urology, University of Cambridge, Cambridge, UK; Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ahmed Alaa
- Department of Electrical and Computer Engineering, University of California, Los Angeles, CA, USA
| | - David Thurtle
- Department of Surgery, Division of Urology, University of Cambridge, Cambridge, UK; Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Mihaela van der Schaar
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, UK; Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Vincent J Gnanapragasam
- Department of Surgery, Division of Urology, University of Cambridge, Cambridge, UK; Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK; Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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316
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Harmon SA, Patel PG, Sanford TH, Caven I, Iseman R, Vidotto T, Picanço C, Squire JA, Masoudi S, Mehralivand S, Choyke PL, Berman DM, Turkbey B, Jamaspishvili T. High throughput assessment of biomarkers in tissue microarrays using artificial intelligence: PTEN loss as a proof-of-principle in multi-center prostate cancer cohorts. Mod Pathol 2021; 34:478-489. [PMID: 32884130 PMCID: PMC9152638 DOI: 10.1038/s41379-020-00674-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 08/21/2020] [Accepted: 08/21/2020] [Indexed: 02/06/2023]
Abstract
Phosphatase and tensin homolog (PTEN) loss is associated with adverse outcomes in prostate cancer and has clinical potential as a prognostic biomarker. The objective of this work was to develop an artificial intelligence (AI) system for automated detection and localization of PTEN loss on immunohistochemically (IHC) stained sections. PTEN loss was assessed using IHC in two prostate tissue microarrays (TMA) (internal cohort, n = 272 and external cohort, n = 129 patients). TMA cores were visually scored for PTEN loss by pathologists and, if present, spatially annotated. Cores from each patient within the internal TMA cohort were split into 90% cross-validation (N = 2048) and 10% hold-out testing (N = 224) sets. ResNet-101 architecture was used to train core-based classification using a multi-resolution ensemble approach (×5, ×10, and ×20). For spatial annotations, single resolution pixel-based classification was trained from patches extracted at ×20 resolution, interpolated to ×40 resolution, and applied in a sliding-window fashion. A final AI-based prediction model was created from combining multi-resolution and pixel-based models. Performance was evaluated in 428 cores of external cohort. From both cohorts, a total of 2700 cores were studied, with a frequency of PTEN loss of 14.5% in internal (180/1239) and external 13.5% (43/319) cancer cores. The final AI-based prediction of PTEN status demonstrated 98.1% accuracy (95.0% sensitivity, 98.4% specificity; median dice score = 0.811) in internal cohort cross-validation set and 99.1% accuracy (100% sensitivity, 99.0% specificity; median dice score = 0.804) in internal cohort test set. Overall core-based classification in the external cohort was significantly improved in the external cohort (area under the curve = 0.964, 90.6% sensitivity, 95.7% specificity) when further trained (fine-tuned) using 15% of cohort data (19/124 patients). These results demonstrate a robust and fully automated method for detection and localization of PTEN loss in prostate cancer tissue samples. AI-based algorithms have potential to streamline sample assessment in research and clinical laboratories.
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Affiliation(s)
- Stephanie A Harmon
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Palak G Patel
- Division of Cancer Biology & Genetics, Cancer Research Institute, Queen's University, Kingston, ON, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
- Department of Cell Biology at The Arthur and Sonia Labatt Brain Tumour Research Centre at the Hospital for Sick Children, Toronto, ON, Canada
| | - Thomas H Sanford
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
- Department of Urology, Upstate Medical University, Syracuse, NY, USA
| | - Isabelle Caven
- Division of Cancer Biology & Genetics, Cancer Research Institute, Queen's University, Kingston, ON, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Rachael Iseman
- Division of Cancer Biology & Genetics, Cancer Research Institute, Queen's University, Kingston, ON, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Thiago Vidotto
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Clarissa Picanço
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Jeremy A Squire
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Samira Masoudi
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Sherif Mehralivand
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Peter L Choyke
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - David M Berman
- Division of Cancer Biology & Genetics, Cancer Research Institute, Queen's University, Kingston, ON, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Baris Turkbey
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Tamara Jamaspishvili
- Division of Cancer Biology & Genetics, Cancer Research Institute, Queen's University, Kingston, ON, Canada.
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada.
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317
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Zhang Y, Mou Y, Liang C, Zhu S, Liu S, Shao P, Li J, Wang Z. Promoting cell proliferation, cell cycle progression, and glycolysis: Glycometabolism-related genes act as prognostic signatures for prostate cancer. Prostate 2021; 81:157-169. [PMID: 33338276 DOI: 10.1002/pros.24092] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/27/2020] [Accepted: 11/16/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Warburg effect seen in most solid tumors occurs only in the late stages of prostate cancer (PCa). Currently, the management of patients with low-risk localized PCa and patients after radical therapy remains a challenge. Our objective here was to evaluate glycometabolism-related genes as prognostic signatures for PCa. METHODS The International Cancer Genome Consortium (ICGC) and The Cancer Genome Atlas (TCGA) databases and glycometabolism-related gene sets were obtained online. Glycometabolic prognostic signatures were identified and validated in a TCGA cohort and tested in an ICGC cohort. We used the gene set enrichment analysis to reveal biological processes associated with the glycometabolism-related signatures. Novel glycometabolism-related genes were selected for verifying their oncogenic phenotypes in vitro. RESULTS Two glycometabolic prognostic signatures were applied respectively to construct risk score formulas for PCa. Survival and receiver operating characteristic curve analyses were performed to detect the value of these prognostic signatures. We performed univariate and multivariate Cox regression analyses in the TCGA cohort, demonstrating the independence of the prognostic signatures. Three glycometabolism-related genes were found to be novel PCa-associated genes. These were shown to affect proliferation, cell cycle progression, and glycolysis of DU145 and PC3 cells in different degrees. CONCLUSION The present research represents the first glycometabolic and high-throughput investigation on PCa, revealing potential biomarkers and treatment targets. We confirm the vital role of glycometabolism in PCa and provide essential resources for future exploration of metabolism in PCa.
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Affiliation(s)
- Yao Zhang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, PR China
| | - Yanhua Mou
- Department of Radiation Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Chao Liang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, PR China
| | - Shenhao Zhu
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, PR China
| | - Shouyong Liu
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, PR China
| | - Pengfei Shao
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, PR China
| | - Jie Li
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, PR China
| | - Zengjun Wang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, PR China
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318
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Contemporary National Trends and Variations of Pelvic Lymph Node Dissection in Patients Undergoing Robot-Assisted Radical Prostatectomy. Clin Genitourin Cancer 2021; 19:309-315. [PMID: 33663952 DOI: 10.1016/j.clgc.2021.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 01/10/2021] [Accepted: 01/17/2021] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Previous studies showed suboptimal adherence to clinical practice guidelines for pelvic lymph node dissection (PLND) during radical prostatectomy (RP). Robot-assisted RP (RARP) has become the predominant surgical management for localized prostate cancer in the United States but contemporary national data on PLND adherence during RARP are still lacking. METHODS RARPs for clinically localized (cT1-2N0M0) intermediate-risk and high-risk prostate cancer diagnosed between 2010 and 2016 in National Cancer Database were identified. Outcome of interest was PLND and multivariable logistic regressions were used to identify whether patient demographics and facility characteristics were associated with the outcome. RESULTS We included 115,355 patients in the final cohort (intermediate-risk = 86,314, high-risk = 29,041). From 2010 to 2016, there was an increasing trend of PLND in the overall, intermediate-risk, and high-risk cohorts. In 2016, PLND was performed in 79.7% of the intermediate-risk and 93.5% of the high-risk patients. Multivariable logistic regressions showed Hispanic race/ethnicity (vs. white) (odds ratio [OR] = 0.90, P = .010), lowest socioeconomic status (vs. highest) (OR = 0.85, P < .001), rural area (vs. metro area) (OR=0.61, P < .001), and community facility (vs. academic) (OR = 0.56, P < .001) were some of the factors associated with lower PLND rate. Variations of PLND rate among reporting facility's locations were also identified. CONCLUSION Contemporary national data showed significantly increased PLND rate in patients who underwent RARP for intermediate-risk and high-risk prostate cancer in recent years. However, there were still some variations in PLND rate among different patient populations and facilities. Continued efforts need to be made to further increase PLND rate and narrow or eliminate disparities we identified.
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319
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Shahait M, Labban M, Dobbs RW, Cheaib JG, Lee DI, Tamim H, El-Hajj A. A 5-Item Frailty Index for Predicting Morbidity and Mortality After Radical Prostatectomy: An Analysis of the American College of Surgeons National Surgical Quality Improvement Program Database. J Endourol 2021; 35:483-489. [PMID: 32935596 DOI: 10.1089/end.2020.0597] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Current preoperative evaluation methods fail to detect the difference in frailty among patients with the same chronological age. Hence, we sought to assess the ability of a simple 5-item frailty index (5-iFI) score to predict surgical outcomes post radical prostatectomy (RP). Methods: The American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent RP between 2008 and 2017. The 5-iFI score was calculated by assigning a point for each of the following conditions: (1) chronic obstructive pulmonary disease or pneumonia, (2) congestive heart failure, (3) dependent functional status, (4) hypertension, and (5) diabetes. Multivariable regression was performed to assess the association between the 5-iFI score and perioperative outcomes. Results: The cohort included 15,546 (46.2%), 14,541 (46.2%), and 3556 (10.6%) patients with 5-iFI scores of 0, 1, and ≥2, respectively. Patients >65 years, nonwhite, and with an American Society of Anesthesiology ≥3 were more likely to have a 5-iFI score ≥2 (p < 0.0001). Similarly, a 5-iFI ≥2 score was associated with higher Clavien-Dindo grades complications (p-trend <0.0001). In addition, a 5-iFI score ≥2 had 1.66 (1.31-2.11) and 1.85 (1.39-2.46) times the odds of Clavien-Dindo grades ≥3 and ≥4 adverse events, respectively. Moreover, a 5-iFI score ≥2 had 28% increased risk of length of stay >1 day (p < 0.0001) and increased incidence of early mortality (p = 0.01). Conclusions: Frailty, as measured by a simple 5-point frailty index, is an independent predictor of adverse outcomes and early mortality in patients undergoing RP. Preoperative frailty assessment may improve risk stratification and patient counseling before surgery.
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Affiliation(s)
- Mohammed Shahait
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Muhieddine Labban
- Division of Urology, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ryan W Dobbs
- Division of Urology, Department of Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Joseph G Cheaib
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David I Lee
- Division of Urology, Department of Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Hani Tamim
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Albert El-Hajj
- Division of Urology, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
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320
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Labbate CV, Paner GP, Eggener SE. Should Grade Group 1 (GG1) be called cancer? World J Urol 2021; 40:15-19. [PMID: 33432506 DOI: 10.1007/s00345-020-03583-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/24/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION ISUP Grade Group 1 prostate cancer is the lowest histologic grade of prostate cancer with a clinically indolent course. Removal of the term 'cancer' has been proposed and has historical precedent both in urothelial and thyroid carcinoma. METHODS Evidence-based review identifying arguments for and against Grade Group 1 being referred to as cancer. RESULTS Grade Group 1 has histologic evidence of tissue microinvasion and 0.3-3% rate of extraprostatic extension. Genomic evaluation suggests overlap of a minority of Grade Group 1 cancers with those of Grade Group 2. Conversely, Grade Group 1 tumors appear to have distinct genetic and genomic profiles from Grade Group 3 or higher tumors. Grade Group 1 has no documented ability for regional or distant metastasis and long-term follow up after treatment or active surveillance is safe with excellent oncologic outcomes. DISCUSSION Grade Group 1 prostate cancer, while showing evidence of neoplasia on histology has a remarkably indolent natural history more akin to non-neoplastic precursor lesions. Consideration should be given to renaming Grade Group 1 prostate cancer, which has the potential to minimize overtreatment, treatment-related side effects, patient anxiety, and financial burden on the healthcare system.
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Affiliation(s)
- Craig V Labbate
- Section of Urology, Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Gladell P Paner
- Department of Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - Scott E Eggener
- Section of Urology, Department of Surgery, University of Chicago Medicine, Chicago, IL, USA.
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321
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Nayak AL, Flaman AS, Mallick R, Lavallée LT, Fergusson DA, Cagiannos I, Morash C, Breau RH. Do androgen-directed therapies improve outcomes in prostate cancer patients undergoing radical prostatectomy? A systematic review and meta-analysis. Can Urol Assoc J 2021; 15:269-279. [PMID: 33443481 DOI: 10.5489/cuaj.7041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Approximately 50% of patients with non-metastatic prostate cancer are treated with radical prostatectomy (RP). While some men will be cured with surgery alone, a substantial proportion will experience cancer recurrence. Androgen-directed therapy (ADT) is an effective adjuvant therapy for patients treated with prostate radiation. Comparatively, the efficacy of ADT in surgical patients has not been well-studied. METHODS A systematic search of MEDLINE, Embase, and the Cochrane Library from inception to July 2020 was performed. Randomized trials comparing ADT with RP vs. prostatectomy alone in patients with clinically localized prostate cancer were included. Neoadjuvant ADT and adjuvant ADT interventions were assessed separately. The primary outcomes were cancer recurrence-free survival (RFS) and overall survival (OS). Pathological outcomes following neoadjuvant ADT were also evaluated. RESULTS Fifteen randomized trials met eligibility criteria; 11 evaluated neoadjuvant ADT (n=2322) and four evaluated adjuvant ADT (n=5205). Neoadjuvant ADT (three months of treatment) did not improve RFS (hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.74-1.11) or OS (HR 1.22, 95% CI 0.62-2.41). Neoadjuvant ADT significantly decreased the risk of positive surgical margins (relative risk [RR] 0.48, 95% CI 0.41-0.56) and extraprostatic tumor extension (RR 0.75, 95% CI 0.64-0.89). Adjuvant ADT improved RFS (HR 0.65, 95% CI 0.45-0.93) but did not improve OS (HR 1.02, 95% CI 0.84-1.24). CONCLUSIONS Neoadjuvant ADT causes a pathological downstaging of prostate tumors but has not been found to delay cancer recurrence nor extend survival. Few studies have evaluated adjuvant ADT. Trials are needed to determine the benefits and harms of intermediate- or long-term adjuvant ADT for RP patients.
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Affiliation(s)
- Ameeta L Nayak
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Ranjeeta Mallick
- Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Luke T Lavallée
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Dean A Fergusson
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ilias Cagiannos
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Chris Morash
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Rodney H Breau
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
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322
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Shahait M, Dobbs RW, Kim JL, Eldred N, Liang K, Huynh LM, Ahlering TE, Patel V, Lee DI. Perioperative and Functional Outcomes of Robot-Assisted Radical Prostatectomy in Octogenarian Men. J Endourol 2021; 35:1025-1029. [PMID: 33267679 DOI: 10.1089/end.2020.0859] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The functional and oncologic outcomes of robot-assisted radical prostatectomy (RARP) in octogenarians are not well studied. We sought to study the perioperative, functional, and oncologic outcomes of RARP in octogenarian men. Methods: Between January 2009 and 2019, 46 patients ≥80 years with localized prostate cancer (PCa) underwent RARP in three high-volume robotic urologic practices in the United States. Clinical and pathologic features, and perioperative and postoperative complications were retrospectively evaluated. Functional outcomes for urinary and sexual function were collected via patient-reported questionnaires. Continence was defined as the use of zero or one safety pad per day. Results: The median (interquartile range) age was 81 (80-82), the mean (standard deviation [SD]) operative time was 116.5 (36.4) minutes, and the mean (SD) blood loss was 132 (35.6) mL. All cases were completed robotically, no intraoperative complications were encountered, and the mean length of stay was 1.21 (0.78) days. Regarding 30- and 90-day complication, nine patients had postoperative complications; seven were Clavien-Dindo grade I-II, and two were Clavien-Dindo grade ≥III. Post-RARP continence rates at 3 and 12 months were 68.4% and 84.8%, respectively. Conclusions: RARP represents a feasible option to treat PCa in well-selected octogenarian men. Careful patient selection and counseling are critical before offering surgical treatment for these men.
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Affiliation(s)
- Mohammed Shahait
- Division of Urology, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,King Hussein Cancer Center, Amman, Jordan
| | - Ryan W Dobbs
- Division of Urology, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jessica L Kim
- Division of Urology, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nancy Eldred
- Advent Health Global Robotics Institute, Celebration, Florida, USA
| | - Karren Liang
- Department Urology, University of California Irvine, Orange, California, USA
| | - Linda M Huynh
- Department Urology, University of California Irvine, Orange, California, USA
| | - Thomas E Ahlering
- Department Urology, University of California Irvine, Orange, California, USA
| | - Vipul Patel
- Advent Health Global Robotics Institute, Celebration, Florida, USA
| | - David I Lee
- Division of Urology, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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323
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MR-Guided High-Intensity Directional Ultrasound Ablation of Prostate Cancer. Curr Urol Rep 2021; 22:3. [PMID: 33403460 DOI: 10.1007/s11934-020-01020-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW The goal of this paper was to review the novel treatment modality of high-intensity transurethral directional ultrasound for prostate cancer. RECENT FINDINGS Prostate cancer is a heterogeneous disease with some patients electing for active surveillance and focal therapies instead of definitive treatment with radical prostatectomy or radiation therapy. Prostate MRI has become a cornerstone of prostate cancer diagnosis, targeted biopsy, and treatment planning. Transurethral high-intensity directional ultrasound allows for MRI-guided ablation of the prostate gland with the ability to contour boundaries and spare critical structures, such as the neurovascular bundle and urinary sphincter. Although results are still emerging, this may offer patients a new option for focal therapy with a favorable side-effect profile. High-intensity transurethral directional ultrasound is an emerging treatment modality for both whole-gland and focal ablation with promising early results. Further research is needed to establish safety, tolerability, and long-term oncologic outcomes.
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324
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Long-term and pathological outcomes of low- and intermediate-risk prostate cancer after radical prostatectomy: implications for active surveillance. World J Urol 2021; 39:3763-3770. [PMID: 33973043 PMCID: PMC8521579 DOI: 10.1007/s00345-021-03717-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 04/27/2021] [Indexed: 02/08/2023] Open
Abstract
PURPOSE The safety of active surveillance (AS) in favorable intermediate-risk (FIR) prostate cancer (PCa) remains uncertain. To provide guidance on clinical decision-making, we examined long-term and pathological outcomes of low-risk and intermediate-risk PCa patients after radical prostatectomy (RP). METHODS The study involved 5693 patients diagnosed between 1994 and 2019 with low-risk, FIR, and unfavorable intermediate-risk (UIR) PCa (stratification according to the AUA guidelines) who underwent RP. Pathological outcomes were compared, and Kaplan-Meier analysis determined biochemical recurrence-free survival (BRFS) and cancer-specific survival (CSS) at 5, 10, 15, and 20 years. Multiple Cox regression was used to simultaneously control for relevant confounders. RESULTS Those at FIR had higher rates of upgrading and upstaging (12.8% vs. 7.2%, p < 0.001; 19.8% vs. 12.0%, p < 0.001) as well as pathological tumor and node stage (≥ pT3a: 18.8% vs. 11.6%, p < 0.001; pN1: 2.7% vs. 0.8%, p > 0.001) compared to patients at low risk. The 20-year BRFS was 69%, 65%, and 44% and the 20-year CSS was 98%, 95%, and 89% in low-risk, FIR, and UIR patients. On multiple Cox regression, FIR was not associated with a worse BRFS (HR 1.07, CI 0.87-1.32), UIR was associated with a worse BRFS (HR 1.49, CI 1.20-1.85). CONCLUSION Patients at FIR had only slightly worse pathological and long-term outcomes compared to patients at low risk, whereas the difference compared to patients at UIR was large. This emphasizes AS in these patients as a possible treatment strategy in well-counseled patients.
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325
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Yan M, Gouveia AG, Cury FL, Moideen N, Bratti VF, Patrocinio H, Berlin A, Mendez LC, Moraes FY. Practical considerations for prostate hypofractionation in the developing world. Nat Rev Urol 2021; 18:669-685. [PMID: 34389825 PMCID: PMC8361822 DOI: 10.1038/s41585-021-00498-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2021] [Indexed: 02/06/2023]
Abstract
External beam radiotherapy is an effective curative treatment option for localized prostate cancer, the most common cancer in men worldwide. However, conventionally fractionated courses of curative external beam radiotherapy are usually 8-9 weeks long, resulting in a substantial burden to patients and the health-care system. This problem is exacerbated in low-income and middle-income countries where health-care resources might be scarce and patient funds limited. Trials have shown a clinical equipoise between hypofractionated schedules of radiotherapy and conventionally fractionated treatments, with the advantage of drastically shortening treatment durations with the use of hypofractionation. The hypofractionated schedules are supported by modern consensus guidelines for implementation in clinical practice. Furthermore, several economic evaluations have shown improved cost effectiveness of hypofractionated therapy compared with conventional schedules. However, these techniques demand complex infrastructure and advanced personnel training. Thus, a number of practical considerations must be borne in mind when implementing hypofractionation in low-income and middle-income countries, but the potential gain in the treatment of this patient population is substantial.
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Affiliation(s)
- Michael Yan
- grid.410356.50000 0004 1936 8331Division of Radiation Oncology, Cancer Centre of Southeastern Ontario, Queen’s University, Kingston, Canada
| | - Andre G. Gouveia
- Department of Radiation Oncology, Americas Centro de Oncologia Integrado, Rio de Janeiro, Brazil
| | - Fabio L. Cury
- grid.14709.3b0000 0004 1936 8649Department of Radiation Oncology, Cedars Cancer Centre, McGill University, Montreal, Canada
| | - Nikitha Moideen
- grid.410356.50000 0004 1936 8331Division of Radiation Oncology, Cancer Centre of Southeastern Ontario, Queen’s University, Kingston, Canada
| | - Vanessa F. Bratti
- grid.410356.50000 0004 1936 8331Queen’s University School of Medicine, Department of Public Health Sciences, Kingston, Canada
| | - Horacio Patrocinio
- grid.14709.3b0000 0004 1936 8649Department of Medical Physics, Cedars Cancer Centre, McGill University, Montreal, Canada
| | - Alejandro Berlin
- grid.17063.330000 0001 2157 2938Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Lucas C. Mendez
- grid.39381.300000 0004 1936 8884Department of Radiation Oncology, London Regional Cancer Program, Western University, London, Canada
| | - Fabio Y. Moraes
- grid.410356.50000 0004 1936 8331Division of Radiation Oncology, Cancer Centre of Southeastern Ontario, Queen’s University, Kingston, Canada
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326
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Loeb S, Giri VN. Clinical Implications of Germline Testing in Newly Diagnosed Prostate Cancer. Eur Urol Oncol 2020; 4:1-9. [PMID: 33390340 DOI: 10.1016/j.euo.2020.11.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/28/2020] [Accepted: 11/30/2020] [Indexed: 12/20/2022]
Abstract
CONTEXT Germline testing (GT) is increasingly impacting prostate cancer (PCa) management and screening, with direct effects in urology, medical oncology, and radiation oncology. The majority of testing indications and recommendations center on men with metastatic disease, although guidelines now encompass newly diagnosed, early-stage PCa and entail assessment of personal history, pathologic features, and family history to determine eligibility for testing. OBJECTIVE To describe current guidelines on GT for men with PCa and the impact on management. An additional objective was to review the literature on current uptake of GT across practice settings. EVIDENCE ACQUISITION A nonsystematic review was performed of current guidelines on GT in PCa from professional societies and consensus conferences, detailing supporting evidence for these recommendations. This was supplemented by a literature review of uptake of GT and precision medicine in practice. EVIDENCE SYNTHESIS Multiple guidelines and consensus panels recommend GT for men with metastatic PCa. Guidelines endorse BRCA2 testing in metastatic PCa because of strong evidence for PCa risk, aggressiveness, and PARP inhibitor candidacy. Testing of additional DNA repair genes in metastatic disease is also endorsed across guidelines. Immunotherapy with pembrolizumab is an option in some guidelines for men with DNA mismatch repair deficiency. In localized disease, GT is recommended on the basis of histologic features and family history; criteria vary between guidelines. GT for localized disease informs hereditary cancer risk and will probably impact future PCa management. Practice gaps exist regarding utilization of GT. CONCLUSIONS Germline evaluation is increasingly important in the management of men with metastatic PCa and may also affect the prognosis for men with localized disease. The presence of germline mutations has important hereditary cancer implications for men and their families. Uptake of germline evaluation may be underutilized in some practice settings, so strategies for optimization are required. PATIENT SUMMARY Patients with prostate cancer should talk to their doctor about the pros and cons of genetic testing, with attention to family history and cancer features. Genetic testing can have important implications for treatment, cancer screening, and family cancer risk.
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Affiliation(s)
- Stacy Loeb
- Department of Urology and Population Health, New York University and Manhattan Veterans Affairs, New York, NY, USA
| | - Veda N Giri
- Cancer Risk Assessment and Clinical Cancer Genetics, Departments of Medical Oncology, Cancer Biology, and Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA.
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327
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Patient-reported Health Status, Comorbidity Burden, and Prostate Cancer Treatment. Urology 2020; 149:103-109. [PMID: 33352164 DOI: 10.1016/j.urology.2020.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 12/03/2020] [Accepted: 12/10/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine whether patient-reported health status, more so than comorbidity, influences treatment in men with localized prostate cancer. METHODS Using Surveillance, Epidemiology, and End Results data linked with Medicare claims and CAHPS surveys, we identified men aged 65-84 diagnosed with localized prostate cancer from 2004 to 2013 and ascertained their National Cancer Institute (NCI) comorbidity score and patient-reported health status. Adjusting for demographics and cancer risk, we examined the relationship between these measures and treatment for the overall cohort, low-risk men aged 65-74, intermediate/high-risk men aged 65-74, and men aged 75-84. RESULTS Among 2724 men, 43.0% rated their overall health as Excellent/Very Good, while 62.7% had a comorbidity score of 0. Beyond age and cancer risk, patient-reported health status was significantly associated with treatment. Compared to men reporting Excellent/Very Good health, men in Poor/Fair health less often received treatment (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.56-0.90). Younger men with intermediate/high-risk cancer in Good (OR 0.60, 95% CI 0.41-0.88) or Fair/Poor (OR 0.49, 95% CI 0.30-0.79) health less often underwent prostatectomy vs radiation compared to men in Excellent/Very Good health. In contrast, men with NCI comorbidity score of 1 more often received treatment (OR 1.37, 95% CI 1.11-1.70) compared to men with NCI comorbidity score of 0. CONCLUSION Patient-reported health status drives treatment for prostate cancer in an appropriate direction whereas comorbidity has an inconsistent relationship. Greater understanding of this interplay between subjective and empiric assessments may facilitate more shared decision-making in prostate cancer care.
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328
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Sayyid RK, Wilson B, Benton JZ, Lodh A, Thomas EF, Goldberg H, Madi R, Terris MK, Wallis CJD, Klaassen Z. Upgrading on radical prostatectomy specimens of very low- and low-risk prostate cancer patients on active surveillance: A population-level analysis. Can Urol Assoc J 2020; 15:E335-E339. [PMID: 33382372 DOI: 10.5489/cuaj.6868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION A proportion of prostate cancer (PCa) patients initially managed with active surveillance (AS) are upgraded to a higher Gleason score (GS) at the time of radical prostatectomy (RP). Our objective was to determine predictors of upgrading on RP specimens using a national database. METHODS The Surveillance, Epidemiology, and End Results Prostate with Watchful Waiting database was used to identify AS patients diagnosed with very low- or low-risk PCa who underwent delayed RP between 2010 and 2015. The primary outcome was upgrading to GS 7 disease or worse. Logistic regression analyses were used to evaluate demographic and oncological predictors of upgrading on final specimen. RESULTS A total of 3775 men underwent RP after a period of AS, 3541 (93.8%) of whom were cT2a; 792 (21.0%) patients were upgraded on RP specimen, with 85.4%, 10.6%, and 3.4% upgraded to GS 7(3+4), 7(4+3), and 8 diseases, respectively. On multivariable analysis, higher prostate-specific antigen (PSA) at diagnosis (5-10 vs. 0-2 ng/ml, odd ratio [OR] 2.59, p<0.001) and percent core involvement (80-100% vs. 0-20%, OR 2.52, p=0.003) were significant predictors of upgrading on final RP specimen, whereas higher socioeconomic status predicted lower odds of upgrading (highest vs. lowest quartile OR 0.75, p=0.013). CONCLUSIONS Higher baseline PSA and percent positive cores involvement are associated with significantly increased risk of upgrading on RP after AS, whereas higher socioeconomic status predicts lower odds of such events. These results may help identify patients at increased risk of adverse pathology on final specimen who may benefit from earlier definitive treatment.
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Affiliation(s)
- Rashid K Sayyid
- Section of Urology, Department of Surgery, Medical College of Georgia-Augusta University, Augusta, GA, United States
| | | | - John Z Benton
- Medical College of Georgia, Augusta, GA, United States
| | - Atul Lodh
- Medical College of Georgia, Augusta, GA, United States
| | - Eric F Thomas
- Section of Urology, Department of Surgery, Medical College of Georgia-Augusta University, Augusta, GA, United States
| | - Hanan Goldberg
- Department of Urology, State University of New York Upstate, Syracuse, NY, United States
| | - Rabii Madi
- Section of Urology, Department of Surgery, Medical College of Georgia-Augusta University, Augusta, GA, United States.,Georgia Cancer Center, Augusta, GA, United States
| | - Martha K Terris
- Section of Urology, Department of Surgery, Medical College of Georgia-Augusta University, Augusta, GA, United States.,Georgia Cancer Center, Augusta, GA, United States
| | | | - Zachary Klaassen
- Section of Urology, Department of Surgery, Medical College of Georgia-Augusta University, Augusta, GA, United States.,Georgia Cancer Center, Augusta, GA, United States
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329
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Frendl DM, FitzGerald G, Epstein MM, Allison JJ, Sokoloff MH, Ware JE. Predicting the 10-year risk of death from other causes in men with localized prostate cancer using patient-reported factors: Development of a tool. PLoS One 2020; 15:e0240039. [PMID: 33284845 PMCID: PMC7721137 DOI: 10.1371/journal.pone.0240039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 09/17/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To develop a tool for estimating the 10-year risk of death from other causes in men with localized prostate cancer. SUBJECTS AND METHODS We identified 2,425 patients from the Surveillance Epidemiology and End Results-Medicare Health Outcomes Survey database, age <80, newly diagnosed with clinical stage T1-T3a prostate cancer from 1/1/1998-12/31/2009, with follow-up through 2/28/2013. We developed a Fine and Gray competing-risks model for 10-year other cause mortality considering age, patient-reported comorbid medical conditions, component scores and items of the SF-36 Health Survey, activities of daily living, and sociodemographic characteristics. Model discrimination and calibration were compared to predictions from Social Security life table mortality risk estimates. RESULTS Over a median follow-up of 7.7 years, 76 men died of prostate-specific causes and 465 died of other causes. The strongest predictors of 10-year other cause mortality risk included increasing age at diagnosis, higher approximated Charlson Comorbidity Index score, worse patient-reported general health (fair or poor vs. excellent-good), smoking at diagnosis, and marital status (all other vs. married) (all p<0.05). Model discrimination improved over Social Security life tables (c-index of 0.70 vs. 0.59, respectively). Predictions were more accurate than predictions from the Social Security life tables, which overestimated risk in our population. CONCLUSIONS We provide a tool for estimating the 10-year risk of dying from other causes when making decisions about treating prostate cancer using pre-treatment patient-reported characteristics.
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Affiliation(s)
- Daniel M. Frendl
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States of America
| | - Gordon FitzGerald
- Department of Surgery Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, United States of America
| | - Mara M. Epstein
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States of America
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States of America
- Meyers Primary Care Institute, Worcester, MA, United States of America
| | - Jeroan J. Allison
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States of America
| | - Mitchell H. Sokoloff
- Department of Urology, University of Massachusetts Medical School, Worcester, MA, United States of America
| | - John E. Ware
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States of America
- John Ware Research Group, Watertown, MA, United States of America
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330
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Venderbos LDF, Deschamps A, Dowling J, Carl EG, Remmers S, van Poppel H, Roobol MJ. Europa Uomo Patient Reported Outcome Study (EUPROMS): Descriptive Statistics of a Prostate Cancer Survey from Patients for Patients. Eur Urol Focus 2020; 7:987-994. [PMID: 33281109 DOI: 10.1016/j.euf.2020.11.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/20/2020] [Accepted: 11/14/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND Europa Uomo initiated the Europa Uomo Patient Reported Outcome Study (EUPROMS) to collect prostate cancer (PCa) patient-reported outcome (PRO) data as a primary endpoint. OBJECTIVE To inform future PCa patients about the impact of PCa treatment through self-reported PRO data of fellow patients collected outside a clinical trial setting. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional survey was conducted among PCa patients currently receiving or having received treatment. The EUPROMS survey contained the EQ-5D-5 L (generic health), the EORTC-QLQ-C30 (cancer-specific quality of life (QoL), and the Expanded Prostate cancer Index Composite short form 26 (EPIC-26; prostate-specific health) questionnaires. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Descriptive statistics were used to assess the demographic and clinical characteristics, and to analyze the PROs of EQ-5D-5L, EORTC-QLQ-C30, and EPIC-26. RESULTS AND LIMITATIONS Between August 21 and November 19, 2019, 2943 men from 24 European countries completed the EUPROMS survey. The median age of the respondents was 71 yr (interquartile range 65-75 yr); 81.9% was living with a spouse. In total, 1937 (65.8%) men underwent a single treatment, and 636 (21.6%), 300 (10.2%), and 70 (2.4%) underwent two, three, and four treatments, respectively. Fatigue scores are highest for men who underwent radiotherapy or chemotherapy. Progression of disease leads to more insomnia. Surgery affects urinary incontinence the most. Self-reported sexual function amounts to 27/100, with the lowest scores being reported for men who underwent surgery and radiotherapy (15/100). Overall, patients who received two or more treatments reported lower scores for all indices. CONCLUSIONS The EUPROMS survey provided a cross-sectional picture of the current PCa patient population and their reported QoL. Initial treatment is often followed by subsequent treatments, affecting mainly sexual function, as well as fatigue and insomnia. QoL of men undergoing chemotherapy is worse for almost all domains. These data can inform physicians and patients on the true impact of PCa treatment. PATIENT SUMMARY Patient-reported quality of life in the Europa Uomo Patient Reported Outcome Study (EUPROMS) survey-a more informal setting as compared with clinical trials-reveals that prostate cancer treatment affects mainly sexual function, fatigue, and insomnia.
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Affiliation(s)
- Lionne D F Venderbos
- Department of Urology, Erasmus University Medical Center Rotterdam, The Netherlands.
| | | | | | | | - Sebastiaan Remmers
- Department of Urology, Erasmus University Medical Center Rotterdam, The Netherlands
| | | | - Monique J Roobol
- Department of Urology, Erasmus University Medical Center Rotterdam, The Netherlands
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331
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Prognostic capabilities and clinical utility of cell cycle progression testing, prostate imaging reporting and data system, version 2, and clinicopathologic data in management of localized prostate cancer. Urol Oncol 2020; 39:366.e19-366.e28. [PMID: 33257218 DOI: 10.1016/j.urolonc.2020.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/08/2020] [Accepted: 11/11/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To compare the prognostic capabilities and clinical utility of the cell cycle progression (CCP) gene expression classifier test, multiparametric magnetic resonance imaging (mpMRI) with Prostate Imaging Reporting and Data System (PI-RADS) scoring, and clinicopathologic data in select prostate cancer (PCa) medical management scenarios. PATIENTS AND METHODS Retrospective, observational analysis of patients (N = 222) ascertained sequentially from a single urology practice from January 2015 to June 2018. Men were included if they had localized PCa, a CCP score, and an mpMRI PI-RADS v2 score. Cohort 1 (n = 156): men with newly diagnosed PCa, with or without a previous negative biopsy. Cohort 2 (n = 66): men who initiated active surveillance (AS) without CCP testing, but who received the test during AS. CCP was combined with the UCSF Cancer of the Prostate Risk Assessment (CAPRA) score to produce a clinical cell-cycle risk (CCR) score, which was reported in the context of a validated AS threshold. Spearman's rank correlation test was used to evaluate correlations between variables. Generalized linear models were used to predict binary Gleason score category and medical management selection (AS or curative therapy). Likelihood-ratio tests were used to determine predictor significance in both univariable and multivariable models. RESULTS In the combined cohorts, modest but significant correlations were observed between PI-RADS score and CCP (rs = 0.22, P = 8.1 × 10-4), CAPRA (rs= 0.36, P = 4.8 × 10-8), or CCR (rs = 0.37, P = 2.0 × 10-8), suggesting that much of the prognostic information captured by these measures is independent. When accounting for CAPRA and PI-RADS score, CCP was a significant predictor of higher-grade tumor after radical prostatectomy, with the resected tumor approximately 4 times more likely to harbor Gleason ≥4+3 per 1-unit increase in CCP in Cohort 1 (Odds Ratio [OR], 4.10 [95% confidence interval [CI], 1.46, 14.12], P = 0.006) and in the combined cohorts (OR, 3.72 [95% CI, 1.39, 11.88], P = 0.008). On multivariable analysis, PI-RADS score was not a significant predictor of post-radical prostatectomy Gleason score. Both CCP and CCR were significant and independent predictors of AS versus curative therapy in Cohort 1 on multivariable analysis, with each 1-unit increase in score corresponding to an approximately 2-fold greater likelihood of selecting curative therapy (CCP OR, 2.08 [95% CI, 1.16, 3.94], P = 0.014) (CCR OR, 2.33 [95% CI, 1.48, 3.87], P = 1.5 × 10-4). CCR at or below the AS threshold significantly reduced the probability of selecting curative therapy over AS (OR, 0.28 [95% CI, 0.13, 0.57], P = 4.4 × 10-4), further validating the clinical utility of the AS threshold. CONCLUSION CCP was a better predictor of both tumor grade and subsequent patient management than was PI-RADS. Even in the context of targeted biopsy, molecular information remains essential to ensure precise risk assessment for men with newly diagnosed PCa.
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332
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Greenland NY, Cowan JE, Chan E, Carroll PR, Stohr BA, Simko JP. Prostate biopsy histopathologic features correlate with a commercial gene expression assay's reclassification of patient NCCN risk category. Prostate 2020; 80:1421-1428. [PMID: 32946625 DOI: 10.1002/pros.24072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/01/2020] [Accepted: 09/04/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND For biopsies with Gleason 3 + 3 = 6 or 3 + 4 = 7 prostate cancer, the Genomic Prostate Score (GPS; OncotypeDx) is designed to predict severe pathology at prostatectomy, and, in some cases, recommends reclassification of the National Comprehensive Cancer Network (NCCN) risk category. We hypothesized that certain histopathologic features that were not considered in the original design of the assay actually would be associated with the NCCN risk category change indicated by GPS testing. METHODS For patients with recommended NCCN risk category change, the biopsy cores used for GPS were re-reviewed for stromal reaction, chronic inflammation, and tumor nuclear polarization. RESULTS Of 520 patients from May 2011 to December 2018, GPS testing suggested NCCN risk reclassification in 131 (25%); 127 of these slides were available. Of these, the NCCN risk category increased from intermediate to high in 8, low to intermediate in 15, very low to low in 1, and decreased from intermediate to low in 32, and low to very low in 71. Biopsies with NCCN risk increase were associated with moderate or severe stromal reaction (p < .001) and chronic inflammation (p < .001); biopsies with NCCN risk decrease were associated with absence of these features. In Gleason 3 + 3 = 6 cases (n = 93), presence of nuclear polarization was associated with NCCN risk decrease and its absence with increase (p < .001). CONCLUSIONS Moderate or severe stromal reaction, chronic inflammation, and lack of nuclear polarization in Gleason score 3 + 3 = 6 tumors were each associated with an increase in NCCN risk category indicated by GPS and vice versa. Our results suggest that GPS captures histologic features associated with aggressiveness that are not routinely assessed in standard histopathologic assessments, and that consideration of such histologic features may improve upon current tumor grading approaches.
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Affiliation(s)
- Nancy Y Greenland
- Department of Anatomic Pathology, University of California, San Francisco, California, USA
- Department of Anatomic Pathology, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Janet E Cowan
- Department of Urology, University of California, San Francisco, California, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA
| | - Emily Chan
- Department of Anatomic Pathology, University of California, San Francisco, California, USA
| | - Peter R Carroll
- Department of Urology, University of California, San Francisco, California, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA
| | - Bradley A Stohr
- Department of Anatomic Pathology, University of California, San Francisco, California, USA
| | - Jeffry P Simko
- Department of Anatomic Pathology, University of California, San Francisco, California, USA
- Department of Urology, University of California, San Francisco, California, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA
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Xia L, Talwar R, Chelluri RR, Guzzo TJ, Lee DJ. Surgical Delay and Pathological Outcomes for Clinically Localized High-Risk Prostate Cancer. JAMA Netw Open 2020; 3:e2028320. [PMID: 33289846 PMCID: PMC7724561 DOI: 10.1001/jamanetworkopen.2020.28320] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
IMPORTANCE There is a lack of data evaluating the association of surgical delay time (SDT) with outcomes in patients with localized, high-risk prostate cancer. OBJECTIVE To investigate the association of SDT of radical prostatectomy and final pathological and survival outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the US National Cancer Database (NCDB) and identified all patients with clinically localized (cT1-2cN0cM0) high-risk prostate adenocarcinoma diagnosed between 2006 and 2016 who underwent radical prostatectomy. Data analyses were performed from April 1 to April 12, 2020. EXPOSURES SDT was defined as the number of days between the initial cancer diagnosis and radical prostatectomy. SDT was categorized into 5 groups: 31 to 60, 61 to 90, 91 to 120, 121 to 150, and 151 to 180 days. MAIN OUTCOMES AND MEASURES The primary outcomes were predetermined as adverse pathological outcomes after radical prostatectomy, including pT3-T4 disease, pN-positive disease, and positive surgical margin. The adverse pathological score (APS) was defined as an accumulated score of the 3 outcomes (0-3). An APS of 2 or higher was considered a separate outcome to capture cases with more aggressive pathological features. The secondary outcome was overall survival. RESULTS Of the 32 184 patients included in the study, the median (interquartile range) age was 64 (59-68) years, and 25 548 (79.4%) were non-Hispanic White. Compared with an SDT of 31 to 60 days, longer SDTs were not associated with higher risks of having any adverse pathological outcomes (odds ratio [OR], 0.95; 95% CI, 0.80-1.12; P = .53), pT3-T4 disease (OR, 0.99; 95% CI, 0.83-1.17; P = .87), pN-positive disease (OR, 0.79; 95% CI, 0.59-1.06; P = .12), positive surgical margin (OR, 0.88; 95% CI, 0.74-1.05; P = .17), or APS greater than or equal to 2 (OR, 0.90; 95% CI, 0.74-1.05; P = .17). Longer SDT was also not associated with worse overall survival (for SDT of 151-180 days, hazard ratio, 1.12; 95% CI, 0.79-1.59, P = .53). Subgroup analyses performed for patients with very high-risk disease (primary Gleason score 5) and sensitivity analyses with SDT considered as a continuous variable yielded similar results. CONCLUSIONS AND RELEVANCE In this cohort study of patients who underwent radical prostatectomy within 180 days of diagnosis for high-risk prostate cancer, radical prostatectomy for high-risk prostate cancer could be safely delayed up to 6 months after diagnosis.
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Affiliation(s)
- Leilei Xia
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Ruchika Talwar
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Raju R. Chelluri
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Thomas J. Guzzo
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Daniel J. Lee
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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334
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Cheung DC, Fleshner N, Sengupta S, Woon D. A narrative review of pelvic lymph node dissection in prostate cancer. Transl Androl Urol 2020; 9:3049-3055. [PMID: 33457278 PMCID: PMC7807357 DOI: 10.21037/tau-20-729] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Pelvic lymph node dissection (PLND) is an important component in the staging and prognostication of prostate cancer. We performed a narrative review to assess the literature surrounding PLND: (I) the current guideline recommendations and contemporary utilization, (II) the calculation of patient-specific risk to perform PLND using available nomograms, (III) to review the extent of dissection, and its associated outcomes and complications. Due to the improved lymph node yield, better staging, and theoretical improvement in the control of micro-metastatic disease, guidelines have supported the use of (extended-) PLND in patients deemed to be at intermediate or high risk of lymph node involvement (often at a threshold of 5% on modern risk nomograms). However, in practice, real-world utilization of PLND varies considerably due to multiple reasons. Conflicting evidence persists with no clear oncological benefit to PLND, and a small, but important, risk of morbidity. Complications are rare, but include lymphoceles; thromboembolic events; and more rarely, obturator nerve, vascular, and ureteric injury. Furthermore, changing disease incidence and stage migration in the context of earlier detection overall have led to a decreased risk of nodal disease. The trade-offs between the benefits, harms, and risk tolerance/threshold must be carefully considered between each patient and their clinician.
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Affiliation(s)
| | - Neil Fleshner
- Division of Urology, University of Toronto, Toronto, Canada
| | - Shomik Sengupta
- Eastern Health Clinical School, Monash University, Melbourne, Australia.,Urology Unit, Eastern Health, Victoria, Australia
| | - Dixon Woon
- Urology Unit, Eastern Health, Victoria, Australia
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335
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Nielsen SB, Spalletta O, Toft Kristensen MA, Brodersen J. Psychosocial consequences of potential overdiagnosis in prostate cancer a qualitative interview study. Scand J Prim Health Care 2020; 38:439-446. [PMID: 33241957 PMCID: PMC7781953 DOI: 10.1080/02813432.2020.1843826] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Prostate cancer is a frequently diagnosed cancer and made up 6% of male cancer deaths globally in 2008. Its incidence varies more than 25-fold worldwide, which is primarily attributed to the implementation of the prostate-specific antigen (PSA) test in developed countries. To reduce harm of overdiagnosis, most international guidelines recommend surveillance programmes. However, this approach can entail negative psychosocial consequences from being under surveillance for an (over)diagnosed prostate cancer. AIM To explore men's feelings and experiences in a surveillance programme. DESIGN AND SETTING Qualitative study with Danish men diagnosed with asymptomatic prostate cancer Gleason score ≤ 6, who are in a surveillance programme. METHODS 12 semi-structured, individual interviews were conducted and analysed with systematic text condensation and selected theories. RESULTS Most informants reported that they were astonished at the time of diagnosis. They were aware of the small likelihood of dying from cancer, but in some cases, the uncertainty created ambivalence between knowing and not knowing. The men expressed their risk awareness in different ways: a realization that life does not last forever, uncertainty towards the future, a feeling of powerlessness, and a need for control. CONCLUSIONS The men in this study had substantial psychosocial consequences from being labelled with a cancer diagnosis. Bearing these men's high risk of overdiagnosis in mind, it is important to discuss whether the harms of this diagnosis outweigh the benefits. The psychosocial consequences of being in a prostate cancer surveillance programme should be explored further. KEY POINTS Current awareness: The number of men living with an asymptomatic prostate cancer has increased the last 20 years after the implementation of the PSA test. Main Statements: Men living with an asymptomatic, low-risk prostate cancer experience negative psychocosial consequences GPs should consider the possible negative psychosocial consequences in their decision-making of measuring the PSA level.
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Affiliation(s)
- Sigrid Brisson Nielsen
- Department of Public Health, University of Copenhagen Faculty of Health Sciences, Section of General Practice & Research Unit for General Practice, Copenhagen, Denmark
- Primary Healthcare Research Unit Region Zealand, Sorø, Denmark
- CONTACT Sigrid Brisson Nielsen Department of Public Health, University of Copenhagen Faculty of Health Sciences, Section of General Practice & Research Unit for General Practice, Sigrid Brisson Nielsen, cand. med, Østerbrogade 84D, 4. Sal, Copenhagen Ø2100, Denmark
| | - Olivia Spalletta
- Department of Public Health, University of Copenhagen Faculty of Health Sciences, Section of General Practice & Research Unit for General Practice, Copenhagen, Denmark
- Brandeis University, Waltham, MA, USA
| | - Mads Aage Toft Kristensen
- Department of Public Health, University of Copenhagen Faculty of Health Sciences, Section of General Practice & Research Unit for General Practice, Copenhagen, Denmark
- Southern Køge Medical Centre. Region Zealand, Køge, Denmark
| | - John Brodersen
- Department of Public Health, University of Copenhagen Faculty of Health Sciences, Section of General Practice & Research Unit for General Practice, Copenhagen, Denmark
- Primary Healthcare Research Unit Region Zealand, Sorø, Denmark
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336
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Washington SL, Jeong CW, Lonergan PE, Herlemann A, Gomez SL, Carroll PR, Cooperberg MR. Regional Variation in Active Surveillance for Low-Risk Prostate Cancer in the US. JAMA Netw Open 2020; 3:e2031349. [PMID: 33369661 PMCID: PMC7770559 DOI: 10.1001/jamanetworkopen.2020.31349] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/04/2020] [Indexed: 01/09/2023] Open
Abstract
Importance Active surveillance (AS) is now recognized as the preferred management option for most low-risk prostate cancers to minimize risks of overtreatment. Despite increasing use of AS in the US, wide regional variability has been observed, and these regional variations in contemporary practice have not been well described. Objective To explore variations between county and Surveillance, Epidemiology, and End Results (SEER) regions in AS in the US. Design, Setting, and Participants A cohort study using the SEER Prostate with Watchful Waiting (WW) database linked to the County Area Health Resource File for detailed county-level demographics and physician distribution data was conducted from January 2010 to December 2015. Analysis was performed in October 2020. A total of 79 825 men with clinically localized, low-risk prostate cancer eligible for AS or WW were included. Exposures Multiple patient-, county-, and SEER region-level factors, including age, year of diagnosis, county-level densities of urologists, radiation oncologists, primary care physicians, and SEER registry region. Main Outcomes and Measures Use of AS or WW as the initial reported treatment strategy were noted. Hierarchical mixed-effect logistic regression models were used to evaluate clustered random regional variation on use of AS or WW. Temporal trends by year in proportions of initial treatment type, as well as county-level local variation, were also estimated. Results Of 79 825 men (mean [SD] age, 62.8 [7.6] years, 11 292 [14.1%] non-Hispanic Black, 7506 [9.4%] Hispanic) with low-risk prostate cancer, the mean annualized percent increase in AS rates from 2010 to 2015 ranged from 6.3% in New Mexico to 81.0% in New Jersey. Differences across SEER regions accounted for 17% of the total variation in AS. Increasing age (51-60 years: odds ratio [OR], 1.33; 95% CI, 1.21-1.46; 61-70 years: OR, 1.86; 95% CI, 1.70-2.04; 71-80 years: OR, 2.26; 95% CI, 2.05-2.50) was associated with greater odds of AS. Hispanic ethnicity (OR, 0.79; 95% CI, 0.74-0.85), T category (OR, 0.79; 95% CI, 0.73-0.84), and Medicaid enrollment (OR, 0.73; 95% CI, 0.66-0.81) were associated with lower odds of AS. Black race, county-level socioeconomic factors (household income, educational level, and city type), and specialist densities were not associated with AS use. Conclusions and Relevance In this US cohort study based on the SEER-WW database, although the use of AS increased, considerable practice variation appeared to be associated with geographic location, but use of AS was not associated with Black race, specialty professional density, or socioeconomic factors. This small area variation underlies the broader national trends in AS practice and may inform policies aimed at continuing to affect risk-appropriate care for men throughout the US.
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Affiliation(s)
- Samuel L. Washington
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco
| | - Chang Wook Jeong
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco
- Department of Urology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Peter E. Lonergan
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco
| | - Annika Herlemann
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco
- Department of Urology, Ludwig–Maximilians–University of Munich, Munich, Germany
| | - Scarlett L. Gomez
- Department of Epidemiology & Biostatistics, University of California, San Francisco
| | - Peter R. Carroll
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco
| | - Matthew R. Cooperberg
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco
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337
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Szymaniak BM, Facchini LA, Giri VN, Antonarakis ES, Beer TM, Carlo MI, Danila DC, Dhawan M, George D, Graff JN, Gupta S, Heath E, Higano CS, Liu G, Molina AM, Paller CJ, Patnaik A, Petrylak DP, Reichert Z, Rettig MB, Ryan CJ, Taplin ME, Vinson J, Whang YE, Morgans AK, Cheng HH, McKay RR. Practical Considerations and Challenges for Germline Genetic Testing in Patients With Prostate Cancer: Recommendations From the Germline Genetics Working Group of the PCCTC. JCO Oncol Pract 2020; 16:811-819. [PMID: 32986533 PMCID: PMC7735040 DOI: 10.1200/op.20.00431] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Germline genetic testing is now routinely recommended for patients with prostate cancer (PCa) because of expanded guidelines and options for targeted treatments. However, integrating genetic testing into oncology and urology clinical workflows remains a challenge because of the increased number of patients with PCa requiring testing and the limited access to genetics providers. This suggests a critical unmet need for genetic services outside of historical models. This review addresses current guidelines, considerations, and challenges for PCa genetic testing and offers a practical guide for genetic counseling and testing delivery, with solutions to help address potential barriers and challenges for both providers and patients. As genetic and genomic testing become integral to PCa care, developing standardized systems for implementation in the clinic is essential for delivering precision oncology to patients with PCa and realizing the full scope and impact of genetic testing.
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Affiliation(s)
- Brittany M. Szymaniak
- Department of Urology, Feinberg School of Medicine at Northwestern University, Chicago, IL
| | | | | | | | - Tomasz M. Beer
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR
| | - Maria I. Carlo
- Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel C. Danila
- Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mallika Dhawan
- Division of Hematology/Oncology, University of California San Francisco, CA
| | - Daniel George
- Division of Medical Oncology, Department of Medicine, and Duke Cancer Institute, Duke University Medical Center, Durham, NC
| | - Julie N. Graff
- Division of Hematology and Medical Oncology, VA Portland Health Care System/Oregon Health & Science University Knight Cancer Institute, Portland, OR
| | - Shilpa Gupta
- Division of Hematology, Oncology, and Transplantation, University of Minnesota Masonic Cancer Center, Minneapolis, MN
| | - Elisabeth Heath
- Karmanos Cancer Institute and Department of Oncology, Wayne State University, Detroit, MI
| | - Celestia S. Higano
- Fred Hutchinson Cancer Research Center and Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Glenn Liu
- University of Wisconsin, Madison, WI
| | - Ana M. Molina
- Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medical College, New York, NY
| | | | - Akash Patnaik
- Department of Medicine, University of Chicago Comprehensive Cancer Center, Chicago, IL
| | | | - Zachery Reichert
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI; University of Michigan Rogel Cancer Center, Ann Arbor, MI
| | - Matthew B. Rettig
- Division of Hematology-Oncology, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | - Charles J. Ryan
- Division of Hematology, Oncology, and Transplantation, University of Minnesota Masonic Cancer Center, Minneapolis, MN
| | - Mary-Ellen Taplin
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA
| | - Jake Vinson
- The Prostate Cancer Clinical Trials Consortium, New York, NY
| | - Young E. Whang
- Department of Medicine, Hematology/Oncology, University of North Carolina Lineberger Cancer Center, Chapel Hill, NC
| | - Alicia K. Morgans
- Division of Hematology/Oncology, Department of Medicine, Feinberg School of Medicine at Northwestern University, Chicago, IL
| | - Heather H. Cheng
- Fred Hutchinson Cancer Research Center and Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Rana R. McKay
- Department of Medicine, University of California at San Diego Moores Cancer Center, La Jolla, CA
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338
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Singh S, Sandhu P, Beckmann K, Santaolalla A, Dewan K, Clovis S, Rusere J, Zisengwe G, Challacombe B, Brown C, Cathcart P, Popert R, Dasgupta P, Van Hemelrijck M, Elhage O. Negative first follow-up prostate biopsy on active surveillance is associated with decreased risk of upgrading, suspicion of progression and converting to active treatment. BJU Int 2020; 128:72-78. [PMID: 33098158 DOI: 10.1111/bju.15281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the risk of disease progression and conversion to active treatment following a negative biopsy while on active surveillance (AS) for prostate cancer (PCa). PATIENTS AND METHODS Men on an AS programme at a single tertiary hospital (London, UK) between 2003 and 2018 with confirmed low-intermediate-risk PCa, Gleason Grade Group <3, clinical stage <T3 and a diagnostic prostate-specific antigen (PSA) level of <20 ng/mL. This cohort included men diagnosed by transrectal ultrasonography guided (12-14 cores) or transperineal (median 32 cores) biopsy. Multivariate Cox hazards regression analysis was undertaken to determine (i) risk of upgrading, (ii) clinical or radiological suspicion of disease progression, and (iii) transitioning to active treatment. Suspicion of disease progression was defined as any biopsy upgrading, >30% positive cores, magnetic resonance imaging (MRI) Likert score >3/T3 or PSA level of >20 ng/mL. Conversion to treatment included radical or hormonal treatment. RESULTS Among the 460 eligible patients, 23% had negative follow-up biopsy findings. The median follow-up was 62 months, with one to two repeat biopsies and two MRIs per patient during that period. Negative biopsy findings at first repeat biopsy were associated with decreased risk of converting to active treatment (hazard ration [HR] 0.18, 95% confidence interval [CI] 0.09-0.37; P < 0.001), suspicion of disease progression (HR 0.56, 95% CI: 0.34-0.94; P = 0.029), and upgrading (HR 0.48, 95% CI 0.23-0.99; P = 0.047). Data are limited by fewer men with multiple follow-up biopsies. CONCLUSION A negative biopsy finding at the first scheduled follow-up biopsy among men on AS for PCa was strongly associated with decreased risk of subsequent upgrading, clinical or radiological suspicion of disease progression, and conversion to active treatment. A less intense surveillance protocol should be considered for this cohort of patients.
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Affiliation(s)
- Sohail Singh
- School of Medical Education, Faculty of Life Sciences and Medicine, King's College London, London, UK.,The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Preeti Sandhu
- School of Medical Education, Faculty of Life Sciences and Medicine, King's College London, London, UK.,The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Kerri Beckmann
- Translational Oncology and Urology Research, Faculty of Life Sciences and Medicine, King's College London, London, UK.,University of South Australia Cancer Research Institute, University of South Australia, Adelaide, SA, Australia
| | - Aida Santaolalla
- Translational Oncology and Urology Research, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Kamal Dewan
- School of Medical Education, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Sharon Clovis
- The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jonah Rusere
- The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Grace Zisengwe
- The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Christian Brown
- The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Paul Cathcart
- The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rick Popert
- The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Prokar Dasgupta
- The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Immunology and Microbial Sciences, Kings College London, London, UK
| | - Mieke Van Hemelrijck
- Translational Oncology and Urology Research, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Oussama Elhage
- The Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Immunology and Microbial Sciences, Kings College London, London, UK
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339
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Schiavina R, Droghetti M, Novara G, Bianchi L, Gaudiano C, Panebianco V, Borghesi M, Piazza P, Mineo Bianchi F, Guerra M, Corcioni B, Fiorentino M, Giunchi F, Verze P, Pultrone C, Golfieri R, Porreca A, Mirone V, Brunocilla E. The role of multiparametric MRI in active surveillance for low-risk prostate cancer: The ROMAS randomized controlled trial. Urol Oncol 2020; 39:433.e1-433.e7. [PMID: 33191117 DOI: 10.1016/j.urolonc.2020.10.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/19/2020] [Accepted: 10/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND We aim to evaluate the impact of multiparametric magnetic resonance imaging and fusion-target biopsy for early reclassification of patients with low-risk Prostate Cancer in a randomized trial. MATERIALS AND METHODS Between 2015 and 2018, patients diagnosed with Prostate Cancer after random biopsy fulfilling PRIAS criteria were enrolled and centrally randomized (1:1 ratio) to study group or control group. Patients randomized to study group underwent multiparametric magnetic resonance imaging at 3 months from enrollment: patients with positive findings (PIRADS-v2>2) underwent fusion-target biopsy; patients with negative multiparametric magnetic resonance imaging or confirmed ISUP - Grade Group 1 at fusion-target biopsy were managed according to PRIAS schedule and 12-core random biopsy was performed at 12 months. Patients in control group underwent PRIAS protocol, including a confirmatory 12-core random biopsy at 12 months. Primary endpoint was a reduction of reclassification rate at 12-month random biopsy in study group at least 20% less than controls. Reclassification was defined as biopsy ISUP Grade Group 1 in >2 biopsy cores or disease upgrading. RESULTS A total of 124 patients were randomized to study group (n = 62) or control group (n = 62). Around 21 of 62 patients (34%) in study group had a positive multiparametric magnetic resonance imaging, and underwent fusion-target biopsy, with 11 (17.7%) reclassifications. Considering the intention-to-treat population, reclassification rate at 12-month random biopsy was 6.5% for study group and 29% for control group, respectively (P < 0.001). CONCLUSIONS The early employment of multiparametric magnetic resonance imaging for active surveillance patients enrolled after random biopsy consents to significantly reduce reclassifications at 12-month random biopsy.
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Affiliation(s)
- Riccardo Schiavina
- Department of Urology, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Matteo Droghetti
- Department of Urology, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy.
| | - Giacomo Novara
- Department of Surgery, Oncology, and Gastroenterology - Urology Clinic University of Padua, Padua, Italy
| | - Lorenzo Bianchi
- Department of Urology, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Caterina Gaudiano
- Department of Radiology, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | | | - Marco Borghesi
- Department of Urology, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Pietro Piazza
- Department of Urology, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Federico Mineo Bianchi
- Department of Urology, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Marco Guerra
- Department of Urology, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Beniamino Corcioni
- Department of Radiology, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Michelangelo Fiorentino
- Department of Pathology, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Francesca Giunchi
- Department of Pathology, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Paolo Verze
- Department of Medicine, Surgery, Dentistry "Scuola Medica Salernitana", University of Salerno, Salerno, Italy
| | - Cristian Pultrone
- Department of Urology, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Rita Golfieri
- Department of Radiology, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Angelo Porreca
- Department of Urology, Policlinico Abano Terme, Abano Terme, Italy
| | - Vincenzo Mirone
- Department of Urology, University of Naples, Federico II, Naples, Italy
| | - Eugenio Brunocilla
- Department of Urology, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
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340
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A 3D-2D Hybrid U-Net Convolutional Neural Network Approach to Prostate Organ Segmentation of Multiparametric MRI. AJR Am J Roentgenol 2020; 216:111-116. [PMID: 32812797 DOI: 10.2214/ajr.19.22168] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Prostate cancer is the most commonly diagnosed cancer in men in the United States with more than 200,000 new cases in 2018. Multiparametric MRI (mpMRI) is increasingly used for prostate cancer evaluation. Prostate organ segmentation is an essential step of surgical planning for prostate fusion biopsies. Deep learning convolutional neural networks (CNNs) are the predominant method of machine learning for medical image recognition. In this study, we describe a deep learning approach, a subset of artificial intelligence, for automatic localization and segmentation of prostates from mpMRI. MATERIALS AND METHODS This retrospective study included patients who underwent prostate MRI and ultrasound-MRI fusion transrectal biopsy between September 2014 and December 2016. Axial T2-weighted images were manually segmented by two abdominal radiologists, which served as ground truth. These manually segmented images were used for training on a customized hybrid 3D-2D U-Net CNN architecture in a fivefold cross-validation paradigm for neural network training and validation. The Dice score, a measure of overlap between manually segmented and automatically derived segmentations, and Pearson linear correlation coefficient of prostate volume were used for statistical evaluation. RESULTS The CNN was trained on 299 MRI examinations (total number of MR images = 7774) of 287 patients. The customized hybrid 3D-2D U-Net had a mean Dice score of 0.898 (range, 0.890-0.908) and a Pearson correlation coefficient for prostate volume of 0.974. CONCLUSION A deep learning CNN can automatically segment the prostate organ from clinical MR images. Further studies should examine developing pattern recognition for lesion localization and quantification.
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341
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Abstract
High-risk prostate cancer is a heterogeneous disease that lacks clear consensus on its ideal management. Historically, non-surgical treatment was the preferred strategy, and several studies demonstrated improved survival among men with high-risk disease managed with the combination of radiotherapy and androgen deprivation therapy (ADT) compared with ADT alone. However, practice trends in the past 10-15 years have shown increased use of radical prostatectomy with pelvic lymph node dissection for primary management of high-risk, localized disease. Radical prostatectomy, as a primary monotherapy, offers the potential benefits of avoiding ADT, reducing rates of symptomatic local recurrence, enabling full pathological tumour staging and potentially reducing late adverse effects such as secondary malignancy compared with radiation therapy. Retrospective studies have reported wide variability in short-term (pathological) and long-term (oncological) outcomes of radical prostatectomy. Surgical monotherapy continues to be appropriate for selected patients, whereas in others the best treatment strategy probably involves a multimodal approach. Appropriate risk stratification utilizing clinical, pathological and potentially also genomic risk data is imperative in the initial management of men with prostate cancer. However, data from ongoing and planned prospective trials are needed to identify the optimal management strategy for men with high-risk, localized prostate cancer.
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342
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Affiliation(s)
- Xinglei Shen
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City
- University of Kansas Cancer Center, Kansas City
| | - Curtis A Pettaway
- Department of Urology, University of Texas, MD Anderson Cancer Center, Houston
| | - Ronald C Chen
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City
- University of Kansas Cancer Center, Kansas City
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343
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Raikhelkar J, Pham M, Lourenco L, Narang N, Chung B, Nguyen A, Kim G, Sayer G, Uriel N. Heart transplantation in patients with localized prostate cancer-Are we denying a life-saving therapy due to an indolent tumor? Clin Transplant 2020; 34:e14080. [PMID: 32941663 DOI: 10.1111/ctr.14080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/09/2020] [Accepted: 08/14/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Prostate cancer (PC) is the most common non-cutaneous cancer in men. Approximately 90% of these cancers are localized (LPC) with a cancer-specific survival rate of 99% at 10 years. Some heart transplant centers (HTCs) regard PC as an absolute contraindication to heart transplantation (HT). This study aims to understand the current status of HT in patients with advanced heart failure (AHF) and concurrent LPC in the United States. METHODS Adult HTCs in the United States were asked to fill out an email questionnaire addressing their current approach to HT in AHF patients with concurrent LPC. RESULTS Fifty of the 90 HTCs that received the questionnaire responded. Only 16% of HTCs had a formal policy regarding HT in patients with LPC, while only 10% had patients with LPC on the HT waitlist at the time of the survey. Overall, 84% of the HTCs had never performed HT in a patient with LPC in the history of their transplant program. CONCLUSION An overwhelming majority of HTCs in the United States do not consider HT an option for AHF patients with concurrent LPC and lack a formal policy regarding the same.
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Affiliation(s)
- Jayant Raikhelkar
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Michael Pham
- Department of Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Laura Lourenco
- Pharmacy Services, University of Chicago, Chicago, IL, USA
| | - Nikhil Narang
- Department of Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Ben Chung
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Ann Nguyen
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Gene Kim
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Gabriel Sayer
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Nir Uriel
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
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344
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Sun W, Shi H, Yuan Z, Xia L, Xiang X, Quan X, Shi W, Jiang L. Prognostic Value of Genes and Immune Infiltration in Prostate Tumor Microenvironment. Front Oncol 2020; 10:584055. [PMID: 33194726 PMCID: PMC7662134 DOI: 10.3389/fonc.2020.584055] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/02/2020] [Indexed: 12/12/2022] Open
Abstract
Background Prostate cancer (PCa) is one of the most common cancers and the fifth leading cause of cancer-related death in men. Immune responses in the tumor microenvironment are hypothesized to be related to the prognosis of PCa patients; however, no studies are available to confirm the same. In this study, we aimed to explore the potential link between these two factors and identify new biomarkers to estimate the survival rate of PCa patients. Methods A total of 490 cases were obtained from The Cancer Genome Atlas (TCGA) database. The gene expression data were analyzed by the ESTIMATE algorithm to evaluate the immune and stromal scores. The survival rate was calculated according to the case-specific clinical data. Enrichment analysis was performed to discover the main biological processes and signaling pathways of immune responses. We further identified and analyzed hub genes in the protein-protein interaction (PPI) network and evaluated their prognostic values. Results Immune score significantly correlated with immune cell infiltration and overall survival of PCa patients. The genes CXCR4 and GPR183, identified as hub genes in the PPI network, correlated with immune cell infiltration and prognosis of PCa patients. Conclusion CXCR4 and GPR183 participate in immune cell infiltration and function in PCa patients. The immune score, as well as the expression of CXCR4 and GPR183 in prostate cancer tissues, could be potential indexes for the prognosis of prostate cancer.
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Affiliation(s)
- Wenguo Sun
- Department of Urology, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Hailin Shi
- Department of Urology, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Zhen Yuan
- Department of Urology, Fuyang People's Hospital, Fuyang, China
| | - Li Xia
- Department of Dermatology, Guilin People's Hospital, Guilin, China
| | - Xuebao Xiang
- Department of Urology, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Xiangfeng Quan
- Department of Urology, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Wenjie Shi
- Department of Gynecology, Pius Hospital of Oldenburg, Oldenburg, Germany
| | - Leiming Jiang
- Department of Urology, Affiliated Hospital of Guilin Medical University, Guilin, China
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345
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Filson CP, Hong F, Xiong N, Pozzar R, Halpenny B, Berry DL. Decision support for men with prostate cancer: Concordance between treatment choice and tumor risk. Cancer 2020; 127:203-208. [PMID: 33119142 DOI: 10.1002/cncr.33241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Decision support tools improve decisional conflict and elicit patient preferences related to prostate cancer treatment. It was hypothesized that men using the Personal Patient Profile-Prostate (P3P) would be more likely to pursue guideline-concordant treatment. METHODS Men from a trial assessing the P3P decision support intervention were identified. The primary exposure was allocation to P3P (vs usual care), and the outcome was appropriate treatment per guidelines (eg, low risk = active surveillance). It was assessed whether providers recommended against any treatment options (ie, restricted). A multivariable model was fit for men with low-risk cancer that estimated the odds of the outcome of interest. RESULTS This study identified 295 men in the cohort: 113 (38%) had low-risk disease, 119 (40%) had favorable intermediate-risk disease, and 63 (21%) had unfavorable intermediate-risk disease. Among low-risk patients, more men pursued active surveillance after using P3P whether they were given unrestricted (62% vs 54% with usual care; P = .54) or restricted options (71% vs 59% with usual care; P = .34). After adjustments, only Black race (odds ratio [OR], 0.31; 95% CI, 0.11-0.89) and restricted options (OR, 0.23; 95% CI, 0.08-0.65) had an inverse association with the receipt of surveillance for patients with low-risk prostate cancer. An impact associated with P3P versus usual care (OR, 0.89; 95% CI, 0.36-2.20) was not observed. CONCLUSIONS Among men in a trial assessing a decision support tool, Black race and restricted treatment options were associated with less use of active surveillance for low-risk prostate cancer. Although the P3P instrument ameliorates decisional conflict, its use was not associated with more appropriate alignment of treatment with disease risk.
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Affiliation(s)
- Christopher P Filson
- Department of Urology, Emory University School of Medicine, Atlanta, Georgia.,Winship Cancer Institute, Emory Healthcare, Atlanta, Georgia.,Department of Urology, Atlanta VA Medical Center, Decatur, Georgia
| | - Fangxin Hong
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Niya Xiong
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Rachel Pozzar
- Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Barbara Halpenny
- Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Donna L Berry
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington.,Department of Urology, University of Washington, Seattle, Washington
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346
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Puneet K, Tilburt JC, Volk RJ, Bennett CL, Qureshi Z, Gershman B, Sedlacek HM, Kim SP. Do radiation oncologists and urologists endorse decision aids for active surveillance of low-risk prostate cancer: Results from a national survey. Eur J Cancer Care (Engl) 2020; 30:e13301. [PMID: 33112008 DOI: 10.1111/ecc.13301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 03/20/2020] [Accepted: 08/07/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The degree decision aids (DAs) can promote active surveillance (AS) for prostate cancer (PCa) remains poorly understood. Herein, we surveyed radiation oncologists (RO) and urologists (URO) about their attitudes towards DAs in counselling patients about AS for low-risk PCa. METHODS We conducted a national survey of RO (n = 915) and URO (n = 940) to assess their attitudes about DAs for AS for patients with low-risk PCa. Respondents were queried about their attitudes towards DAs and proportion of PCa patients managed with AS. Multivariable logistic regression models were used to examine physician characteristics related to attitudes about DAs. RESULTS The overall response rate was 37.3% (n = 691). Most respondents strongly agreed or agreed that DAs helped patients with low-risk PCa make informed decisions (93.9%) and also increased patient support for AS (86.6%). Having a high volume of their low-risk PCa patients on AS (>15%) was associated with endorsing the statement that use of DAs increased the likelihood of recommending AS (OR: 1.83; 95% CI: 1.00-4.61; p = .05) and being a URO versus a RO (OR: 3.37; 95% CI: 2.46-5.79; p < .001). CONCLUSIONS Most specialists view DAs as effective tools to facilitate more informed treatment decisions and facilitate greater use of AS in appropriately selected patients.
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Affiliation(s)
- Kang Puneet
- Northeast Ohio Medical University, Canal Fulton, OH, USA
| | - Jon C Tilburt
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Center of Bioethics, Mayo Clinic, Rochester, MN, USA
| | - Robert J Volk
- Department of Health Services Research, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles L Bennett
- College of Pharmacy, University of South Carolina, Columbia, SC, USA.,School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Zaina Qureshi
- School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Boris Gershman
- Division of Urology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Hillary M Sedlacek
- Case Comprehensive Cancer Center, Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Simon P Kim
- Division of Urology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
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347
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Chung JS, Morgan TM, Hong SK. Clinical implications of genomic evaluations for prostate cancer risk stratification, screening, and treatment: a narrative review. Prostate Int 2020; 8:99-106. [PMID: 33102389 PMCID: PMC7557186 DOI: 10.1016/j.prnil.2020.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/06/2020] [Indexed: 02/08/2023] Open
Abstract
New classification systems based on molecular features have been introduced to improve precision medicine for prostate cancer (PCa). This review covers the increasing risk of PCa and the differences in response to targeted therapy that are related to specific gene variations. We believe that genomic evaluations will be useful for guiding PCa risk stratification, screening, and treatment. We searched the PubMed and MEDLINE databases for articles related to genomic testing for PCa that were published in 2020 or earlier. There is increasing evidence that germline mutations in DNA repair genes, such as BRCA1/2 or ATM, are closely related to the development and aggressiveness of PCa. Targeted prostate-specific antigen screening based on the presence of germline alterations in DNA repair genes is recommend to achieve an early diagnosis of PCa. In cases of localized PCa, even if it has a favorable risk classification, patients under active surveillance with these gene alterations are likely to develop aggressive PCa. Thus, active treatment may be preferable to active surveillance for these patients. In cases of metastatic castration–resistant PCa, BRCA1/2 and DNA mismatch repair genes may be useful biomarkers for predicting the response to androgen receptor–targeting agents, poly (ADP-ribose) polymerase inhibitors, platinum chemotherapy, prostate-specific membrane antigen–targeted therapy, immunotherapy, and radium-223. Genomic evaluations may allow for risk stratification of patients with PCa based on their molecular features, which may help guide precision medicine for treating PCa.
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Affiliation(s)
- Jae-Seung Chung
- Department of Urology, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Todd M Morgan
- Department of Urology, University of Michigan, Rogel Cancer Center, Ann Arbor, MI, USA
| | - Sung Kyu Hong
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea.,Department of Urology, Seoul National University Bundang Hospital, Seongnam-si, Korea
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348
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Ghali F, Daly WC, Hansen M, Hayn M, Sammon J, Beaule LT, Sarkar R, Murphy J, Kader AK, Derweesh I, Rose B, Ryan ST. Pathologic nodal downstaging in men with clinically involved lymph nodes undergoing radical prostatectomy: Implications for definitive locoregional therapy. Urol Oncol 2020; 39:130.e1-130.e7. [PMID: 33121914 DOI: 10.1016/j.urolonc.2020.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 11/26/2022]
Abstract
A prostate cancer (CaP) patient with nonmetastatic but clinical positive lymph nodes (cN+) represents a difficult clinical scenario. We compare overall survival (OS) between cN+ men that underwent radical prostatectomy (RP) and were found to have negative node status (pN) with those found to have positive nodal status (pN+), and assess predictors of discordant nodal status. We queried the National Cancer Data Base between 2004 and 2015 for patients that were cT1-3 cN+ cM0 CaP treated with RP. Patients with 0 nodes, cT4, or cM1 disease were excluded. We compared groups based on pathologic nodal status: Discordant (cN+ -> pN) & Concordant (cN+ -> pN+). Kaplan Meier estimations were used to compare OS. Logistic regression was used to determine possible predictors of nodal status. We find that of 6470 cN+ patients, 1,367 (21.1%) underwent RP, 866 (13.4%) had confirmed nodal status. Discordant status was found in 159 (18.4%) and concordant staging in 707 (81.6%). Differences exist in PSA at diagnosis (7.3 vs. 11.2), biopsy group, # of nodes examined (7 vs. 10), race, and Charlson index. Discordant staging had longer OS compared to Concordant staging (P = 0.007) and similar OS to a 3:1 matched cohort of high risk localized CaP patients used as reference (P = 0.46). Lower Gleason Score (GG1-3) was associated with an increased likelihood of discordant staging. Clinical nodal staging is associated with a substantial false positive rate. Discordant status had better OS than Concordant status and similar OS to matched patients with localized CaP. Clinical nodal staging may inappropriately lead to noncurative therapy in a substantial number of men with potentially curable disease.
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Affiliation(s)
- Fady Ghali
- Department of Urology, University of California, San Diego, CA.
| | | | - Moritz Hansen
- Division of Urology, Maine Medical Center, Portland, ME
| | - Matthew Hayn
- Division of Urology, Maine Medical Center, Portland, ME
| | - Jesse Sammon
- Division of Urology, Maine Medical Center, Portland, ME
| | - Lisa T Beaule
- Division of Urology, Maine Medical Center, Portland, ME
| | - Reith Sarkar
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, CA
| | - James Murphy
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, CA
| | - A Karim Kader
- Department of Urology, University of California, San Diego, CA
| | - Ithaar Derweesh
- Department of Urology, University of California, San Diego, CA
| | - Brent Rose
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, CA
| | - Stephen T Ryan
- Department of Urology, University of California, San Diego, CA
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349
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Singh S, Patil S, Tamhankar AS, Ahluwalia P, Gautam G. Low-risk prostate cancer in India: Is active surveillance a valid treatment option? Indian J Urol 2020; 36:184-190. [PMID: 33082633 PMCID: PMC7531380 DOI: 10.4103/iju.iju_37_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/08/2020] [Accepted: 05/03/2020] [Indexed: 01/24/2023] Open
Abstract
Introduction and Objective: Carcinoma prostate is considered highly aggressive in Asian countries such as India. This raises an argument whether active surveillance (AS) gives a false sense of security as opposed to upfront radical prostatectomy (RP) in Indian males with low-risk prostate cancer (PCa). We analyzed our prospectively maintained robot-assisted RP (RARP) database to address this question. Materials and Methods: Five hundred and sixty-seven men underwent RARP by a single surgical team from September 2013 to September 2019. Of these, 46 (8.1%) were low risk considering the National Comprehensive Cancer Network criteria. Gleason grade group and stage were compared before and after surgery to ascertain the incidence of upgrading and upstaging. Preoperative clinical and pathological characteristics were analyzed for association with the probability of upstaging and upgrading. Results: The mean age was 60.8 ± 6.8 years. Average prostate-specific antigen level was 6.7 ± 2.0 ng/mL. 40 (86.9%) patients had a T1 stage disease and 6 (13%) patients were clinically in T2a stage. A total of 25 (54.3%) cases were either upstaged or upgraded, 19 (41.3%) showed no change, and the remaining 2 (4.3%) had no malignancy on the final RP specimen. Upstaging occurred in 8 (17.4%) cases: 5 (10.9%) to pT3a and 3 (6.5%) to pT3b. Upgrading occurred in 23 (50%) cases: 19 (41.3%) to Grade 2; 3 (6.5%) to Grade 3; and 1 (2.2%) to Grade 4. Conclusions: There is a 50% likelihood of upstaging or upgrading in Indian males with low-risk PCa eligible for AS. Decision to proceed with AS should be taken carefully.
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Affiliation(s)
- Shanky Singh
- Department of Urology, AIIMS, Rishikesh, Uttarakhand, India
| | - Saurabh Patil
- Department of Urooncology, Max Institute of Cancer Care, New Delhi, India
| | | | - Puneet Ahluwalia
- Department of Urooncology, Max Institute of Cancer Care, New Delhi, India
| | - Gagan Gautam
- Department of Urooncology, Max Institute of Cancer Care, New Delhi, India
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350
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French WW, Wallen EM. Advances in the diagnostic options for prostate cancer. Postgrad Med 2020; 132:52-62. [PMID: 32900250 DOI: 10.1080/00325481.2020.1822067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Over the past decade, despite the controversies surrounding prostate cancer screening, significant refinements have improved its application. PSA screening, although it has been questioned, appears to confer a mortality benefit and remains the most effective way to identify the possible presence of prostate cancer. Methods to improve the specificity of PSA screening and limit overdiagnosis of indolent cancers, including risk-stratified screening regimens, are currently being utilized. Certain imaging modalities, such as multiparametric MRI, have proven to be excellent adjuncts providing improved risk stratification and the ability for targeted biopsies; however, concerns over variability in interpretation and generalizability persist. A number of novel biomarkers have become available with nearly all demonstrating the ability to improve upon the specificity of PSA screening; however, optimal timing, direct comparisons, and usefulness in conjunction with imaging modalities remain to be elucidated. With the improvement in testing options and recognition of the risk/benefit ratio for men undergoing screening for prostate cancer, the increasing role of shared decision making in the process is emphasized.
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Affiliation(s)
- William W French
- Department of Urology, University of North Carolina Medical Center , Chapel Hill, NC, United States
| | - Eric M Wallen
- Department of Urology, University of North Carolina Medical Center , Chapel Hill, NC, United States
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