1
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Al Hussein Al Awamlh B, Wu X, Barocas DA, Moses KA, Hoffman RM, Basourakos SP, Lewicki P, Smelser WW, Arenas-Gallo C, Shoag JE. Intensity of observation with active surveillance or watchful waiting in men with prostate cancer in the United States. Prostate Cancer Prostatic Dis 2022:10.1038/s41391-022-00580-z. [PMID: 35882950 DOI: 10.1038/s41391-022-00580-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/27/2022] [Accepted: 07/14/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Population-based studies assessing various active surveillance (AS) protocols for prostate cancer, to date, have inferred AS participation by the lack of definitive treatment and use of post-diagnostic testing. This is problematic as evidence suggests that most men do not adhere to AS protocols. We sought to develop a novel method of identifying men on AS or watchful waiting (WW) independent of post-diagnostic testing and aimed to identify possible predictors of follow-up intensity in men on AS/WW. METHODS A predictive model was developed using SEER watchful waiting data to identify men ≥66 years on AS between 2010-2015, irrespective of post-diagnostic testing, and applied to SEER-Medicare database. AS intensity among different variables including age, prostate-specific antigen (PSA) level, number of total and positive biopsy cores, Charlson comorbidity index, race (Black vs. non-Black), US census region, and county poverty, income, and education levels were compared using multivariable regression analyses for PSA testing, surveillance biopsy, and magnetic resonance imaging (MRI). RESULTS A total of 2238 men were identified as being on AS. Of which, 81%, 33%, and 10% had a PSA test, surveillance biopsy, and MRI scan within 1-2 years, respectively. On multivariable analyses, Black men were less likely to have a PSA test (adjusted rate ratio [ARR] 0.60, 95% CI: 0.53-0.69), MRI scan (ARR 0.40, 95% CI: 0.24-0.68), and surveillance biopsy (ARR 0.71, 95% CI: 0.55-0.92) than non-Black men. Men within the highest income quintile were more likely to undergo PSA test (ARR 1.16, 95% CI: 1.05-1.27) and MRI scan (ARR 1.60, 95% CI 1.15-2.27) compared to men with the lowest income. CONCLUSIONS Black men and men with lower incomes on AS underwent less rigorous monitoring. Further study is needed to understand and ameliorate differences in AS rigor stemming from sociodemographic differences.
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Affiliation(s)
| | - Xian Wu
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY, USA
| | - Daniel A Barocas
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelvin A Moses
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard M Hoffman
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Spyridon P Basourakos
- Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Patrick Lewicki
- Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Woodson W Smelser
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Camilo Arenas-Gallo
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH, USA
| | - Jonathan E Shoag
- Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA.,Department of Urology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH, USA
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2
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Raposeiras-Roubin S, Abu-Assi E, Marchán A, Fernández-Sanz T, Barreiro-Pardal C, Pousa IM, Erquicia PD, Ledo-Piñeiro A, González-Bermúdez I, Viu MM, Íñiguez-Romo A. Validation of Embolic and Bleeding Risk Scores in Patients With Atrial Fibrillation and Cancer. Am J Cardiol 2022; 180:44-51. [DOI: 10.1016/j.amjcard.2022.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 11/29/2022]
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3
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Incidence and Predictors of Bleeding in Patients With Cancer and Atrial Fibrillation. Am J Cardiol 2022; 167:139-146. [PMID: 35027138 DOI: 10.1016/j.amjcard.2021.11.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/24/2021] [Accepted: 11/29/2021] [Indexed: 11/22/2022]
Abstract
Despite patients with cancer having a higher incidence of atrial fibrillation (AF), little is known about the predictors of outcomes in this population. This study aimed to assess the incidence and predictors of bleeding in patients with AF and cancer. The study population comprised 16,056 patients from a Spanish health area diagnosed with AF between 2014 and 2018 (1,137 with cancer). Competing risk analysis were used to evaluate the association of cancer and bleeding. Discrimination and calibration of bleeding risk scores were assessed by the concordance statistic and the Brier score, respectively. During a median follow-up of 4.9 years, the incidence of bleeding in patients with cancer was 13.2 per 100 patients/year. After multivariate adjustment, a significant association between cancer and bleeding was detected (subdistribution hazard ratio [sHR] 1.18, 95% CI 1.07 to 1.30, p = 0.001), specifically in patients with active cancer or previous radiotherapy. Early age, male gender, diabetes, and anticoagulation were independent predictors of bleeding. However, only anticoagulation with vitamin K antagonist (sHR 1.36, 95% CI 1.03 to 1.78, p = 0.026), not with direct oral anticoagulants (sHR 1.25, 95% CI 0.84 to 1.85, p = 0.270), was associated with bleeding. Discrimination and calibration of Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly, and Drugs/alcohol concomitantly (HAS-BLED), AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA), and Hepatic or renal disease, Ethanol abuse, Malignancy, Older (age ≥75 years), Reduced platelet count or function, Rebleeding risk, Hypertension, Anaemia, Genetic factors, Excessive fall risk and Stroke (HEMORR2HAGES) scores were poor in patients with cancer (concordance statistic <0.6 and Brier score >0.1). In summary, cancer was associated with an increased risk of bleeding in patients with AF. The predictive ability of bleeding risk scores was poor in this population. Anticoagulation with vitamin K antagonist but not with direct oral anticoagulants, was an independent predictor of bleeding in patients with cancer.
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Basak R, Usinger DS, Chen RC, Shen X. Patient Decision-Making Factors in Aggressive Treatment of Low-Risk Prostate Cancer. JNCI Cancer Spectr 2022; 6:6506527. [PMID: 35699497 PMCID: PMC8857916 DOI: 10.1093/jncics/pkac003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/28/2021] [Accepted: 10/30/2021] [Indexed: 11/24/2022] Open
Abstract
Background Active surveillance (AS) is underutilized for low-risk prostate cancer. This study examines decision-making factors associated with AS vs aggressive treatment in a population-based cohort of low-risk patients. Methods Newly diagnosed patients (n = 599) were enrolled through the North Carolina Central Cancer Registry from 2011 to 2013 and surveyed regarding 5 factors that may impact treatment decision making: perceived cancer aggressiveness, aggressiveness of treatment intent, most important goal (eg, cure, quality of life), primary information source, and primary decision maker. We examined the association between treatment decision-making factors with patient choice for AS vs aggressive treatment using multivariable logistic regression analysis. Results This is a sociodemographically diverse cohort reflective of the population-based design, with 37.6% overall (47.6% among very low-risk patients) choosing AS. Aggressive treatment intent (odds ratio [OR] = 7.09, 95% confidence interval [CI] = 4.57 to 11.01), perceived cancer aggressiveness (OR = 4.93, 95% CI = 2.71 to 8.97), most important goal (cure vs other, OR = 1.72, 95% CI = 1.12 to 2.63), and primary information source (personal and family vs physician, OR = 1.76, 95% CI = 1.10 to 2.82) were associated with aggressive treatment. Overall, 88.4% of patients (92.2% among very low-risk) who indicated an intent to treat the cancer “not very aggressively” chose AS. Conclusions These data from the patient’s perspective shed new light on potentially modifiable factors that can help further increase AS uptake among low-risk patients. Helping more low-risk patients feel comfortable with a “not very aggressive” treatment approach may be especially important, which can be facilitated through patient education interventions to improve the understanding of the cancer diagnosis and AS having a curative intent.
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Affiliation(s)
- Ramsankar Basak
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Deborah S Usinger
- University of North Carolina-Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Ronald C Chen
- University of Kansas Medical Center, Department of Radiation Oncology, Kansas City, KS, USA
| | - Xinglei Shen
- University of Kansas Medical Center, Department of Radiation Oncology, Kansas City, KS, USA
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5
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Ellis SD, Hwang S, Morrow E, Kimminau KS, Goonan K, Petty L, Ellerbeck E, Thrasher JB. Perceived barriers to the adoption of active surveillance in low-risk prostate cancer: a qualitative analysis of community and academic urologists. BMC Cancer 2021; 21:649. [PMID: 34058998 PMCID: PMC8165996 DOI: 10.1186/s12885-021-08386-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical practice guidelines recommend active surveillance as the preferred treatment option for low-risk prostate cancer, but only a minority of eligible men receive active surveillance, and practice variation is substantial. The aim of this study is to describe barriers to urologists' recommendation of active surveillance in low-risk prostate cancer and explore variation of barriers by setting. METHODS We conducted semi-structured interviews among 22 practicing urologists, evenly distributed between academic and community practice. We coded barriers to active surveillance according to a conceptual model of determinants of treatment quality to identify potential opportunities for intervention. RESULTS Community and academic urologists were generally in agreement on factors influencing active surveillance. Urologists perceived patient-level factors to have the greatest influence on recommendations, particularly tumor pathology, patient age, and judgements about the patient's ability to adhere to follow-up protocols. They also noted cross-cutting clinical barriers, including concerns about the adequacy of biopsy samples, inconsistent protocols to guide active surveillance, and side effects of biopsy procedures. Urologists had differing opinions on the impact of environmental factors, such as financial disincentives and fear of litigation. CONCLUSIONS Despite national and international recommendations, both academic and community urologists note a variety of barriers to implementing active surveillance in low risk prostate cancer. These barriers will need to be specifically addressed in efforts to help urologists offer active surveillance more consistently.
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Affiliation(s)
- Shellie D. Ellis
- Department of Population Health, School of Medicine, University of Kansas, Kansas City, KS USA
| | - Soohyun Hwang
- Department of Health Policy and Management, School of Public Health, University of North Carolina Chapel Hill, 135 Dauer Drive, 1101 McGavran-Greenberg Hall, Chapel Hill, NC 27599-7411 USA
| | - Emily Morrow
- Department of Sociology, University of Kansas, Kansas City, KS USA
| | - Kim S. Kimminau
- Department of Family Medicine, School of Medicine, University of Kansas, Kansas City, KS USA
| | - Kelly Goonan
- Independent Researcher/Consultant/Scientific Writer, Greensboro, NC USA
| | - Laurie Petty
- Department of Sociology, University of Kansas, Kansas City, KS USA
| | - Edward Ellerbeck
- Department of Population Health, School of Medicine, University of Kansas, Kansas City, KS USA
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6
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Arterial thromboembolic events preceding the diagnosis of cancer in older persons. Blood 2018; 133:781-789. [PMID: 30578253 DOI: 10.1182/blood-2018-06-860874] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/14/2018] [Indexed: 01/03/2023] Open
Abstract
Cancer patients face an increased risk of arterial thromboembolism; however, it is uncertain when this excess risk begins. This study evaluated the risk of arterial thromboembolism before cancer diagnosis. Using the population-based Surveillance Epidemiology and End Results-Medicare linked dataset, we identified 374 331 patients ≥67 years of age with a new primary diagnosis of breast, lung, prostate, colorectal, bladder, uterine, pancreatic, gastric cancer, or non-Hodgkin lymphoma from 2005 through 2013. Cancer patients were individually matched by demographics and comorbidities to Medicare beneficiaries without cancer, who served as controls. Validated diagnosis codes were used to identify arterial thromboembolic events, defined as a composite of myocardial infarction or ischemic stroke. The Mantel-Haenszel estimator was used to compare risks of arterial thromboembolic events between cancer and noncancer groups during 30-day periods in the 360 days before date of cancer diagnosis. From 360 to 151 days before cancer diagnosis, the 30-day interval risks of arterial thromboembolic events were similar between cancer patients and matched controls. From 150 to 1 day before cancer diagnosis, the interval 30-day risks of arterial thromboembolic events were higher in cancer patients vs matched controls, progressively increasing as the cancer diagnosis date approached and peaking during the 30 days immediately before cancer diagnosis, when 2313 (0.62%) cancer patients were diagnosed with an arterial thromboembolic event vs 413 (0.11%) controls (odds ratio, 5.63; 95% confidence interval, 5.07-6.25). In conclusion, the risk of arterial thromboembolic events begins to increase 150 days before the date of cancer diagnosis in older persons and peaks in the 30 days before.
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7
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Huo J, Ray-Zack MD, Shan Y, Chamie K, Boorjian SA, Kerr P, Jana B, Freedland SJ, Kamat AM, Mehta HB, Williams SB. Discerning Patterns and Quality of Neoadjuvant Chemotherapy Use Among Patients with Muscle-invasive Bladder Cancer. Eur Urol Oncol 2018; 2:497-504. [PMID: 31411998 DOI: 10.1016/j.euo.2018.07.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/03/2018] [Accepted: 07/23/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy is underutilized in bladder cancer patients who undergo radical cystectomy. However, the quality of regimens used in this setting remains largely unknown. OBJECTIVE To determine utilization treatment patterns and survival outcomes according to regimens administered. DESIGN, SETTING, AND PATIENTS We used the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database to identify patients diagnosed with clinical stage TII-IV bladder cancer from January 1, 2001 to December 31, 2011. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Temporal trends were assessed using the Cochran-Armitage test. Multivariable logistic regression models were used to identify predictors for neoadjuvant chemotherapy use. Cox proportional hazards models were used to compare overall survival according to regimens administered. RESULTS AND LIMITATIONS Of 2738 patients treated with radical cystectomy, 344 (12.6%) received neoadjuvant chemotherapy. The agents most commonly used were gemcitabine (72.3%), cisplatin (55.2%), and carboplatin (31.1%). The regimens most commonly used were gemcitabine-cisplatin (45.3%), gemcitabine-carboplatin (24.1%), and methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC; 6.7%). Use of neoadjuvant chemotherapy more than tripled during the study period, from 5.7% in 2001 to 17.3% in 2011 (p<0.001). The quality of the regimen administered impacted survival outcomes, as M-VAC use was significantly associated with better overall survival among patients diagnosed with stage II bladder cancer (hazard ratio 0.24, 95% confidence interval 0.07-0.86; p=0.030]. Limitations include the limited ability of retrospective analysis to control for selection bias. CONCLUSIONS Neoadjuvant chemotherapy was underused, and the quality of neoadjuvant chemotherapy regimens administered for bladder cancer was inconsistent with guideline recommendations. These findings are important when interpreting population-based data on the use of chemotherapy and extrapolating survival outcomes. PATIENT SUMMARY In a large population-based study, 12.6% of patients undergoing radical cystectomy for bladder cancer received neoadjuvant chemotherapy, half of whom received guideline-recommended regimens. The quality of the regimen impacted survival outcomes, as use of cisplatin-based chemotherapy was significantly associated with better overall survival among patients diagnosed with stage II bladder cancer. However, <1% of radical cystectomy patients received this regimen.
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Affiliation(s)
- Jinhai Huo
- Department of Health Services Research, Management and Policy, The University of Florida, Gainesville, FL, USA
| | - Mohamed D Ray-Zack
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Yong Shan
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Karim Chamie
- Department of Urology, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Preston Kerr
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Bagi Jana
- Department of Hematology and Oncology, The University of Texas Medical Branch, Galveston, TX, USA
| | | | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hemalkumar B Mehta
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Stephen B Williams
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA.
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8
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Kraus RD, Hamilton AS, Carlos M, Ballas LK. Using hospital medical record data to assess the accuracy of the SEER Los Angeles Cancer Surveillance Program for initial treatment of prostate cancer: a small pilot study. Cancer Causes Control 2018; 29:815-821. [PMID: 30022335 DOI: 10.1007/s10552-018-1057-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 07/12/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Treatment information from the Surveillance, Epidemiology, and End Result Program (SEER) cancer registries is increasingly being used for population-based cancer research; however, it may be incomplete for outpatient procedures and is not quality controlled. We sought to validate SEER information on initial treatment of prostate cancer by comparison to electronic medical record (EMR) review. METHODS Patients diagnosed with prostate cancer between 1 January 2010 and 31 December 2014 in Los Angeles County who received treatment at our institution within 6 months of diagnosis were identified from the SEER registry. We reviewed the hospital EMR for these patients and identified initial treatment received within 6 months of diagnosis. We compared data reported to SEER data to our re-abstracted hospital EMR data (defined as the gold standard) to identify the completeness of SEER treatment data (sensitivity) and the accuracy of the SEER information (positive predictive value). RESULTS Based on 266 eligible patients, SEER's sensitivity in capturing initial treatment was 95.9% (118/123) for prostatectomy, 95.8% (69/72) for no treatment, 87.5% (21/24) for radiation therapy, 68.3% (28/41) for active surveillance or watchful waiting, and 50.0% (2/4) for cryosurgery. The SEER positive predictive value was 100% for radiation therapy and cryosurgery, 97.5% (118/121) for radical prostatectomy, 82.3% (28/34) for active surveillance or watchful waiting, and 78.4% (69/88) for no treatment. CONCLUSION The SEER data were highly sensitive and has a high positive predictive value for surgery and radiation therapy but underreported use of active surveillance. These results may assist researchers in understanding the strengths and weaknesses of using SEER prostate cancer treatment data.
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Affiliation(s)
- Ryan D Kraus
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, 1441 Eastlake Ave, Norris G350, Los Angeles, CA, 90033, USA
| | - Ann S Hamilton
- Department of Preventative Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Mari Carlos
- University of Southern California, Los Angeles, CA, USA
| | - Leslie K Ballas
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, 1441 Eastlake Ave, Norris G350, Los Angeles, CA, 90033, USA.
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9
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Filson CP. Quality of care and economic considerations of active surveillance of men with prostate cancer. Transl Androl Urol 2018; 7:203-213. [PMID: 29732278 PMCID: PMC5911536 DOI: 10.21037/tau.2017.08.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The current health care climate mandates the delivery of high-value care for patients considering active surveillance for newly-diagnosed prostate cancer. Value is defined by increasing benefits (e.g., quality) for acceptable costs. This review discusses quality of care considerations for men contemplating active surveillance, and highlights cost implications at the patient, health-system, and societal level related to pursuit of non-interventional management of men diagnosed with localized prostate cancer. In general, most quality measures are focused on prostate cancer care in general, rather that active surveillance patients specifically. However, most prostate cancer quality measures are pertinent to men seeking close observation of their prostate tumors with active surveillance. These include accurate documentation of clinical stage, informed discussion of all treatment options, and appropriate use of imaging for less-aggressive prostate cancer. Furthermore, interventions that may help improve the quality of care for active surveillance patients are reviewed (e.g., quality collaboratives, judicious antibiotic use, etc.). Finally, the potential economic impact and benefits of broad acceptance of active surveillance strategies are highlighted.
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Affiliation(s)
- Christopher P Filson
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA.,Atlanta Veterans Administration Medical Center, Decatur, GA, USA
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10
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Jiang S, Narayan V, Warlick C. Racial disparities and considerations for active surveillance of prostate cancer. Transl Androl Urol 2018; 7:214-220. [PMID: 29732279 PMCID: PMC5911544 DOI: 10.21037/tau.2017.09.11] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Active surveillance (AS) for the management of low-risk prostate cancer has been increasing and in the general population appears safe, allowing for a reduction in the harms of prostate cancer screening such as overtreatment. African-American (AA) men have overall worse outcomes from prostate cancer compared to Caucasian-American (CA) men for a variety of socioeconomic, cultural and possibly biologic reasons, thus complicating the use of AS in this population. Strategies for optimizing care and mitigating risk in this population include pursuing close surveillance with steadfast patient compliance, the use of multiparametric MRI with targeted biopsies including the anterior prostate to reduce the risk of undersampling, as well as a judicious and thoughtful incorporation of novel molecular biomarkers for risk stratification. Currently, there exists no direct data to suggest that AS cannot be safely carried out in AA men following an informed discussion and after engaging in shared decision making. Physicians should have a low threshold for consideration of definitive therapy. Additional efforts should be made in increasing the engagement of minority participants in clinical trials, to gain an improved representation of underserved populations in future research.
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Affiliation(s)
- Song Jiang
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
| | - Vikram Narayan
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
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11
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Pesapane F, Patella F, Fumarola EM, Zanchetta E, Floridi C, Carrafiello G, Standaert C. The prostate cancer focal therapy. Gland Surg 2018; 7:89-102. [PMID: 29770305 PMCID: PMC5938267 DOI: 10.21037/gs.2017.11.08] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 10/31/2017] [Indexed: 12/21/2022]
Abstract
Despite prostate cancer (PCa) is the leading form of non-cutaneous cancer in men, most patients with PCa die with disease rather than of the disease. Therefore, the risk of overtreatment should be considered by clinicians who have to distinguish between patients with high risk PCa (who would benefit from radical treatment) and patients who may be managed more conservatively, such as through active surveillance or emerging focal therapy (FT). The aim of FT is to eradicate clinically significant disease while protecting key genito-urinary structures and function from injury. While effectiveness studies comparing FT with conventional care options are still lacking, the rationale supporting FT relies on evidence-based advances such as the understanding of the index lesion's central role in the natural history of the PCa and the improvement of multiparametric magnetic resonance imaging (mpMRI) in the detection and risk stratification of PCa. In this literature review, we want to highlight the rationale for FT in PCa management and the current evidence on patient eligibility. Furthermore, we summarize the best imaging modalities to localize the target lesion, describe the current FT techniques in PCa, provide an update on their oncological outcomes and highlight trends for future research.
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Affiliation(s)
- Filippo Pesapane
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy
| | - Francesca Patella
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy
| | - Enrico Maria Fumarola
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy
| | - Edoardo Zanchetta
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, Milan, Italy
| | - Chiara Floridi
- Azienda Ospedaliera Fatebenefratelli e Oftalmico, Milan, Italy
| | - Gianpaolo Carrafiello
- Department of Health Sciences, Diagnostic and Interventional Radiology, San Paolo Hospital, University of Milan, Milan, Italy
| | - Chloë Standaert
- Department of Radiology, Ghent University Hospital, Ghent, Belgium
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12
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Davis K, Bellini P, Hagerman C, Zinar R, Leigh D, Hoffman R, Aaronson D, Van Den Eeden S, Philips G, Taylor K. Physicians' Perceptions of Factors Influencing the Treatment Decision-making Process for Men With Low-risk Prostate Cancer. Urology 2017; 107:86-95. [PMID: 28454988 PMCID: PMC5880528 DOI: 10.1016/j.urology.2017.02.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/28/2017] [Accepted: 02/08/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess physicians' attitudes regarding multiple factors that may influence recommendations for active surveillance (AS) vs active treatment (AT) given the central role physicians play in the treatment decision-making process. MATERIALS AND METHODS We conducted semistructured interviews to assess factors that physicians consider important when recommending AS vs AT, as well as physicians' perceptions of what their patients consider important in the decision. Participants included urologists (N = 11), radiation oncologists (N = 12), and primary care physicians (N = 10) from both integrated and fee-for-service healthcare settings. RESULTS Across the specialties, quantitative data indicated that most physicians reported that their recommendations for AS were influenced by patients' older age, willingness and ability to follow a surveillance protocol, anxiety, comorbidities, life expectancy, and treatment preferences. Qualitative findings highlighted physicians' concerns about malpractice lawsuits, given the possibility of disease progression. Additionally, most physicians noted the role of the healthcare setting, suggesting that financial incentives may be associated with AT recommendations in fee-for-service settings. Finally, most physicians reported spouse or family opposition to AS due to their own anxiety or lack of understanding of AS. CONCLUSION We found that patient and physician preferences, healthcare setting, and family or spouse factors influence physicians' treatment recommendations for men with low-risk PCa. These were consistent themes across physician subspecialties in both an Health Maintenance Organization and in fee-for-service settings.
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Affiliation(s)
- Kimberly Davis
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC.
| | - Paula Bellini
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC
| | - Charlotte Hagerman
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC
| | - Riley Zinar
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC
| | - Daniel Leigh
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC
| | - Richard Hoffman
- Division of General Internal Medicine, University of Iowa Carver College of Medicine/Iowa City VA Medical Center, Iowa City, IA
| | - David Aaronson
- Department of Urology, Kaiser Permanente, East Bay, Oakland, CA
| | | | - George Philips
- Department of Medicine, MedStar Georgetown University Hospital Center, Washington, DC
| | - Kathryn Taylor
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC
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Abstract
BACKGROUND The risk of arterial thromboembolism in patients with cancer is incompletely understood. OBJECTIVES The authors aimed to better define this epidemiological relationship, including the effects of cancer stage. METHODS Using the Surveillance Epidemiology and End Results-Medicare linked database, the authors identified patients with a new primary diagnosis of breast, lung, prostate, colorectal, bladder, pancreatic, or gastric cancer or non-Hodgkin lymphoma from 2002 to 2011. They were individually matched by demographics and comorbidities to a Medicare enrollee without cancer, and each pair was followed through 2012. Validated diagnosis codes were used to identify arterial thromboembolism, defined as myocardial infarction or ischemic stroke. Cumulative incidence rates were calculated using competing risk survival statistics. Cox hazards analysis was used to compare rates between groups at discrete time points. RESULTS The authors identified 279,719 pairs of patients with cancer and matched control patients. The 6-month cumulative incidence of arterial thromboembolism was 4.7% (95% confidence interval [CI]: 4.6% to 4.8%) in patients with cancer compared with 2.2% (95% CI: 2.1% to 2.2%) in control patients (hazard ratio [HR]: 2.2; 95% CI: 2.1 to 2.3). The 6-month cumulative incidence of myocardial infarction was 2.0% (95% CI: 1.9% to 2.0%) in patients with cancer compared with 0.7% (95% CI: 0.6% to 0.7%) in control patients (HR: 2.9; 95% CI: 2.8 to 3.1). The 6-month cumulative incidence of ischemic stroke was 3.0% (95% CI: 2.9% to 3.1%) in patients with cancer compared with 1.6% (95% CI: 1.6% to 1.7%) in control patients (HR: 1.9; 95% CI: 1.8 to 2.0). Excess risk varied by cancer type (greatest for lung), correlated with cancer stage, and generally had resolved by 1 year. CONCLUSIONS Patients with incident cancer face a substantially increased short-term risk of arterial thromboembolism.
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Hagerman CJ, Bellini PG, Davis KM, Hoffman RM, Aaronson DS, Leigh DY, Zinar RE, Penson D, Van Den Eeden S, Taylor KL. Physicians' perspectives on the informational needs of low-risk prostate cancer patients. HEALTH EDUCATION RESEARCH 2017; 32:134-152. [PMID: 28380628 PMCID: PMC5914350 DOI: 10.1093/her/cyx035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 01/27/2017] [Indexed: 06/07/2023]
Abstract
Despite the evidence indicating that decision aids (DA) improve informed treatment decision making for prostate cancer (PCa), physicians do not routinely recommend DAs to their patients. We conducted semi-structured interviews with urologists (n = 11), radiation oncologists (n = 12) and primary care physicians (n = 10) about their methods of educating low-risk PCa patients regarding the treatment decision, their concerns about recommending DAs, and the essential content and format considerations that need to be addressed. Physicians stressed the need for providing comprehensive patient education before the treatment decision is made and expressed concern about the current unevaluated information available on the Internet. They made recommendations for a DA that is brief, applicable to diverse populations, and that fully discloses all treatment options (including active surveillance) and their potential side effects. Echoing previous studies showing that low-risk PCa patients are making rapid and potentially uninformed treatment decisions, these results highlight the importance of providing patient education early in the decision-making process. This need may be fulfilled by a treatment DA, should physicians systematically recommend DAs to their patients. Physicians' recommendations for the inclusion of particular content and presentation methods will be important for designing a high quality DA that will be used in clinical practice.
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Affiliation(s)
- Charlotte J. Hagerman
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington DC 20007, USA
| | - Paula G. Bellini
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington DC 20007, USA
| | - Kim M. Davis
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington DC 20007, USA
| | - Richard M. Hoffman
- Division of General Internal Medicine, University of Iowa Carver College of Medicine/Iowa City VA Medical Center, Iowa City, IA 52242, USA
| | - David S. Aaronson
- Department of Urology, Kaiser Permanente, East Bay, Oakland, CA 94611, USA
| | - Daniel Y. Leigh
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington DC 20007, USA
| | - Riley E. Zinar
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington DC 20007, USA
| | - David Penson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN 37232-2765, USA
| | | | - Kathryn L. Taylor
- Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington DC 20007, USA
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15
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Leapman MS, Cowan JE, Nguyen HG, Shinohara KK, Perez N, Cooperberg MR, Catalona WJ, Carroll PR. Active Surveillance in Younger Men With Prostate Cancer. J Clin Oncol 2017; 35:1898-1904. [PMID: 28346806 DOI: 10.1200/jco.2016.68.0058] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Purpose The suitability of younger patients with prostate cancer (PCa) for initial active surveillance (AS) has been questioned on the basis of eventual treatment necessity and concerns of safety; however, the role of age on surveillance outcomes has not been well defined. Patients and Methods We identified men managed with AS at our institution with a minimum follow-up of 6 months. The primary study objective was to examine the association of age with risk of biopsy-based Gleason score upgrade during AS. We also examined the association of age with related end points, including overall biopsy-determined progression, definitive treatment, and pathologic and biochemical outcomes after delayed radical prostatectomy (RP), using descriptive statistics, the Kaplan-Meier method, and multivariable Cox proportional hazards regression. Results A total of 1,433 patients were followed for a median of 49 months; 74% underwent initial biopsy at a referring institution. Median age at diagnosis was 63 years, including 599 patients (42%) ≤ 60 years old and 834 (58%) > 60 years old. The 3- and 5-year biopsy-based Gleason score upgrade-free rates were 73% and 55%, respectively, for men ≤ 60 years old compared with 64% and 48%, respectively, for men older than 60 years ( P < .01). On Cox regression analysis, younger age was independently associated with lower risk of biopsy-based Gleason score upgrade (hazard ratio per 1-year decrease, 0.969 [95% CI, 0.956 to 0.983]; P < .01), and persisted upon restriction to men meeting strict AS inclusion criteria. There was no significant association between younger age and risk of definitive treatment or risk of biochemical recurrence after delayed RP. Conclusion Younger patient age was associated with decreased risk of biopsy-based Gleason score upgrade during AS but not with risk of definitive treatment in the intermediate term. AS represents a strategy to mitigate overtreatment in young patients with low-risk PCa in the early term.
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Affiliation(s)
- Michael S Leapman
- Michael S. Leapman, Janet E. Cowan, Hao G. Nguyen, Katsuto K. Shinohara, Nannette Perez, Matthew R. Cooperberg, and Peter R. Carroll, University of California, San Francisco, CA; William J. Catalona, Northwestern University, Chicago, IL; and Michael S. Leapman, Yale University School of Medicine, New Haven, CT
| | - Janet E Cowan
- Michael S. Leapman, Janet E. Cowan, Hao G. Nguyen, Katsuto K. Shinohara, Nannette Perez, Matthew R. Cooperberg, and Peter R. Carroll, University of California, San Francisco, CA; William J. Catalona, Northwestern University, Chicago, IL; and Michael S. Leapman, Yale University School of Medicine, New Haven, CT
| | - Hao G Nguyen
- Michael S. Leapman, Janet E. Cowan, Hao G. Nguyen, Katsuto K. Shinohara, Nannette Perez, Matthew R. Cooperberg, and Peter R. Carroll, University of California, San Francisco, CA; William J. Catalona, Northwestern University, Chicago, IL; and Michael S. Leapman, Yale University School of Medicine, New Haven, CT
| | - Katsuto K Shinohara
- Michael S. Leapman, Janet E. Cowan, Hao G. Nguyen, Katsuto K. Shinohara, Nannette Perez, Matthew R. Cooperberg, and Peter R. Carroll, University of California, San Francisco, CA; William J. Catalona, Northwestern University, Chicago, IL; and Michael S. Leapman, Yale University School of Medicine, New Haven, CT
| | - Nannette Perez
- Michael S. Leapman, Janet E. Cowan, Hao G. Nguyen, Katsuto K. Shinohara, Nannette Perez, Matthew R. Cooperberg, and Peter R. Carroll, University of California, San Francisco, CA; William J. Catalona, Northwestern University, Chicago, IL; and Michael S. Leapman, Yale University School of Medicine, New Haven, CT
| | - Matthew R Cooperberg
- Michael S. Leapman, Janet E. Cowan, Hao G. Nguyen, Katsuto K. Shinohara, Nannette Perez, Matthew R. Cooperberg, and Peter R. Carroll, University of California, San Francisco, CA; William J. Catalona, Northwestern University, Chicago, IL; and Michael S. Leapman, Yale University School of Medicine, New Haven, CT
| | - William J Catalona
- Michael S. Leapman, Janet E. Cowan, Hao G. Nguyen, Katsuto K. Shinohara, Nannette Perez, Matthew R. Cooperberg, and Peter R. Carroll, University of California, San Francisco, CA; William J. Catalona, Northwestern University, Chicago, IL; and Michael S. Leapman, Yale University School of Medicine, New Haven, CT
| | - Peter R Carroll
- Michael S. Leapman, Janet E. Cowan, Hao G. Nguyen, Katsuto K. Shinohara, Nannette Perez, Matthew R. Cooperberg, and Peter R. Carroll, University of California, San Francisco, CA; William J. Catalona, Northwestern University, Chicago, IL; and Michael S. Leapman, Yale University School of Medicine, New Haven, CT
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16
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Krishna S, Fan Y, Jarosek S, Adejoro O, Chamie K, Konety B. Racial Disparities in Active Surveillance for Prostate Cancer. J Urol 2017; 197:342-349. [DOI: 10.1016/j.juro.2016.08.104] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Suprita Krishna
- Department of Urology, University of Minnesota, Minneapolis, Minnesota
- Department of Urology, University of California, Los Angeles, Los Angeles, California
| | - Yunhua Fan
- Department of Urology, University of Minnesota, Minneapolis, Minnesota
- Department of Urology, University of California, Los Angeles, Los Angeles, California
| | - Stephanie Jarosek
- Department of Urology, University of Minnesota, Minneapolis, Minnesota
- Department of Urology, University of California, Los Angeles, Los Angeles, California
| | - Oluwakayode Adejoro
- Department of Urology, University of Minnesota, Minneapolis, Minnesota
- Department of Urology, University of California, Los Angeles, Los Angeles, California
| | - Karim Chamie
- Department of Urology, University of Minnesota, Minneapolis, Minnesota
- Department of Urology, University of California, Los Angeles, Los Angeles, California
| | - Badrinath Konety
- Department of Urology, University of Minnesota, Minneapolis, Minnesota
- Department of Urology, University of California, Los Angeles, Los Angeles, California
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Duggan MA, Anderson WF, Altekruse S, Penberthy L, Sherman ME. The Surveillance, Epidemiology, and End Results (SEER) Program and Pathology: Toward Strengthening the Critical Relationship. Am J Surg Pathol 2016; 40:e94-e102. [PMID: 27740970 PMCID: PMC5106320 DOI: 10.1097/pas.0000000000000749] [Citation(s) in RCA: 279] [Impact Index Per Article: 34.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute collects data on cancer diagnoses, treatment, and survival for approximately 30% of the United States (US) population. To reflect advances in research and oncology practice, approaches to cancer control are evolving from simply enumerating the development of cancers by organ site in populations to including monitoring of cancer occurrence by histopathologic and molecular subtype, as defined by driver mutations and other alterations. SEER is an important population-based resource for understanding the implications of pathology diagnoses across demographic groups, geographic regions, and time and provides unique insights into the practice of oncology in the US that are not attainable from other sources. It provides incidence, survival, and mortality data for histopathologic cancer subtypes, and data by molecular subtyping are expanding. The program is developing systems to capture additional biomarker data, results from special populations, and expand biospecimen banking to enable cutting-edge cancer research and oncology practice. Pathology has always been central and critical to the effectiveness of SEER, and strengthening this relationship in this modern era of cancer diagnosis could be mutually beneficial. Achieving this goal requires close interactions between pathologists and the SEER program. This review provides a brief overview of SEER, focuses on facets relevant to pathology practice and research, and highlights the opportunities and challenges for pathologists to benefit from and enhance the value of SEER data.
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Affiliation(s)
- Máire A. Duggan
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - William F. Anderson
- Divisions of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Sean Altekruse
- Cancer Control and Populations Sciences, National Cancer Institute, Bethesda, Maryland, USA
| | - Lynne Penberthy
- Cancer Control and Populations Sciences, National Cancer Institute, Bethesda, Maryland, USA
| | - Mark E. Sherman
- Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
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18
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Williams SB, Chapin BF. Patterns of Care for Prostate Cancer Patients: Predictors of Care, But For Whom? Eur Urol 2016; 71:738-739. [PMID: 27815080 DOI: 10.1016/j.eururo.2016.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 10/11/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Stephen B Williams
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Brian F Chapin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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19
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Van Hemelrijck M, Garmo H, Lindhagen L, Bratt O, Stattin P, Adolfsson J. Quantifying the Transition from Active Surveillance to Watchful Waiting Among Men with Very Low-risk Prostate Cancer. Eur Urol 2016; 72:534-541. [PMID: 27816297 DOI: 10.1016/j.eururo.2016.10.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 10/17/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Active surveillance (AS) is commonly used for men with low-risk prostate cancer (PCa). When life expectancy becomes too short for curative treatment to be beneficial, a change from AS to watchful waiting (WW) follows. Little is known about this change since it is rarely documented in medical records. OBJECTIVE To model transition from AS to WW and how this is affected by age and comorbidity among men with very low-risk PCa. DESIGN, SETTING, AND PARTICIPANTS National population-based healthcare registers were used for analysis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Using data on PCa characteristics, age, and comorbidity, a state transition model was created to estimate the probability of changes between predefined treatments to estimate transition from AS to WW. RESULTS AND LIMITATIONS Our estimates indicate that 48% of men with very low-risk PCa starting AS eventually changed to WW over a life course. This proportion increased with age at time of AS initiation. Within 10 yr from start of AS, 10% of men aged 55 yr and 50% of men aged 70 yr with no comorbidity at initiation changed to WW. Our prevalence simulation suggests that the number of men on WW who were previously on AS will eventually stabilise after 30 yr. A limitation is the limited information from clinical follow-up visits (eg, repeat biopsies). CONCLUSIONS We estimated that changes from AS to WW become common among men with very low-risk PCa who are elderly. This potential change to WW should be discussed with men starting on AS. Moreover, our estimates may help in planning health care resources allocated to men on AS, as the transition to WW is associated with lower demands on outpatient resources. PATIENT SUMMARY Changes from active surveillance to watchful waiting will become more common among men with very low-risk prostate cancer. These observations suggest that patients need to be informed about this potential change before they start on active surveillance.
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Affiliation(s)
- Mieke Van Hemelrijck
- Cancer Epidemiology Group, Division of Cancer Studies, King's College London, London, UK; Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden.
| | - Hans Garmo
- Cancer Epidemiology Group, Division of Cancer Studies, King's College London, London, UK; Regional Cancer Centre Uppsala, Akademiska Sjukhuset, Uppsala, Sweden
| | | | - Ola Bratt
- Department of Translational Medicine Urology, Division of Urological Cancer, Lund University, Lund, Sweden; CamPARI Clinic, Department of Urology, Cambridge University Hospitals, Cambridge, UK
| | - Pär Stattin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University Hospital, Umeå, Sweden
| | - Jan Adolfsson
- CLINTEC Department, Karolinska Institute, Stockholm, Sweden
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20
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Holtz JN, Tay KJ, Polascik TJ, Gupta RT. Integration of multiparametric MRI into active surveillance of prostate cancer. Future Oncol 2016; 12:2513-2529. [DOI: 10.2217/fon-2016-0142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Prostate cancer is the most common noncutaneous cancer in men though many men will not die of this disease and may not require definitive treatment. Active surveillance (AS) is an increasingly utilized potential solution to the issue of overtreatment of prostate cancer. Traditionally, prostate cancer patients have been stratified into risk groups based on clinical stage on digital rectal examination, prostate-specific antigen and biopsy Gleason score, though each of these variables has significant limitations. This review will discuss the potential role for prostate multiparametric MRI and targeted biopsy techniques incorporating MRI in the selection of candidates for AS, monitoring patients on AS and as triggers for definitive treatment.
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Affiliation(s)
- Jamie N Holtz
- Duke University Medical Center, Department of Radiology, DUMC Box 3808, Durham, NC 27710, USA
| | - Kae Jack Tay
- Duke University Medical Center, Department of Surgery, Division of Urologic Surgery & Duke Prostate Center, DUMC Box 2804, Durham, NC 27710, USA
| | - Thomas J Polascik
- Duke University Medical Center, Department of Surgery, Division of Urologic Surgery & Duke Prostate Center, DUMC Box 2804, Durham, NC 27710, USA
- Duke Cancer Institute, DUMC Box 3494, 20 Duke Medicine Circle, Durham, NC 27710, USA
| | - Rajan T Gupta
- Duke University Medical Center, Department of Radiology, DUMC Box 3808, Durham, NC 27710, USA
- Duke Cancer Institute, DUMC Box 3494, 20 Duke Medicine Circle, Durham, NC 27710, USA
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21
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Loeb S, Walter D, Curnyn C, Gold HT, Lepor H, Makarov DV. How Active is Active Surveillance? Intensity of Followup during Active Surveillance for Prostate Cancer in the United States. J Urol 2016; 196:721-6. [PMID: 26946161 PMCID: PMC5010531 DOI: 10.1016/j.juro.2016.02.2963] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2016] [Indexed: 11/23/2022]
Abstract
PURPOSE While major prostate cancer active surveillance programs recommend repeat testing such as prostate specific antigen and prostate biopsy, to our knowledge compliance with such testing is unknown. We determined whether men in the community receive the same intensity of active surveillance testing as in prospective active surveillance protocols. MATERIALS AND METHODS We performed a retrospective cohort study of men 66 years old or older in the SEER (Surveillance, Epidemiology and End Results)-Medicare database. These men were diagnosed with prostate cancer from 2001 to 2009, did not receive curative therapy in the year after diagnosis and underwent 1 or more post-diagnosis prostate biopsies. We used multivariable adjusted Poisson regression to determine the association of the frequency of active surveillance testing with patient demographics and clinical features. In 1,349 men with 5 years of followup we determined the proportion who underwent testing as intense as that recommended by the Sunnybrook Health Sciences Centre and PRIAS (Prostate Cancer Research International Active Surveillance) programs, including 14 or more PSA tests and 2 or more biopsies, and The Johns Hopkins program, including 10 or more prostate specific antigen tests and 4 or more biopsies. RESULTS Among 5,192 patients undergoing active surveillance greater than 80% had 1 or more prostate specific antigen tests per year but fewer than 13% underwent biopsy beyond the first 2 years. Magnetic resonance imaging was rarely done during the study period. On multivariable analysis recent diagnosis and higher income were associated with a higher frequency of surveillance biopsy while older age and greater comorbidity were associated with fewer biopsies. African American men underwent fewer prostate specific antigen tests but a similar number of biopsies. During 5 years of active surveillance only 11.1% and 5.0% of patients met the testing standards of the Sunnybrook/PRIAS and The Johns Hopkins programs, respectively. CONCLUSIONS In the community few elderly men receive the intensity of active surveillance testing recommended in major prospective active surveillance programs.
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Affiliation(s)
- Stacy Loeb
- Department of Urology, New York University, New York, New York; Population Health, New York University, New York, New York; Laura and Isaac Perlmutter Cancer Center, New York University, New York, New York.
| | - Dawn Walter
- Population Health, New York University, New York, New York
| | - Caitlin Curnyn
- Population Health, New York University, New York, New York
| | - Heather T Gold
- Population Health, New York University, New York, New York
| | - Herbert Lepor
- Department of Urology, New York University, New York, New York
| | - Danil V Makarov
- Department of Urology, New York University, New York, New York; Population Health, New York University, New York, New York; Laura and Isaac Perlmutter Cancer Center, New York University, New York, New York
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22
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Tonry CL, Leacy E, Raso C, Finn SP, Armstrong J, Pennington SR. The Role of Proteomics in Biomarker Development for Improved Patient Diagnosis and Clinical Decision Making in Prostate Cancer. Diagnostics (Basel) 2016; 6:E27. [PMID: 27438858 PMCID: PMC5039561 DOI: 10.3390/diagnostics6030027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/28/2016] [Accepted: 07/07/2016] [Indexed: 02/06/2023] Open
Abstract
Prostate Cancer (PCa) is the second most commonly diagnosed cancer in men worldwide. Although increased expression of prostate-specific antigen (PSA) is an effective indicator for the recurrence of PCa, its intended use as a screening marker for PCa is of considerable controversy. Recent research efforts in the field of PCa biomarkers have focused on the identification of tissue and fluid-based biomarkers that would be better able to stratify those individuals diagnosed with PCa who (i) might best receive no treatment (active surveillance of the disease); (ii) would benefit from existing treatments; or (iii) those who are likely to succumb to disease recurrence and/or have aggressive disease. The growing demand for better prostate cancer biomarkers has coincided with the development of improved discovery and evaluation technologies for multiplexed measurement of proteins in bio-fluids and tissues. This review aims to (i) provide an overview of these technologies as well as describe some of the candidate PCa protein biomarkers that have been discovered using them; (ii) address some of the general limitations in the clinical evaluation and validation of protein biomarkers; and (iii) make recommendations for strategies that could be adopted to improve the successful development of protein biomarkers to deliver improvements in personalized PCa patient decision making.
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Affiliation(s)
- Claire L Tonry
- UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin 4, Ireland.
| | - Emma Leacy
- UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin 4, Ireland.
| | - Cinzia Raso
- UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin 4, Ireland.
| | - Stephen P Finn
- School of Medicine, Trinity College Dublin, Dublin 2, Ireland.
| | | | - Stephen R Pennington
- UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin 4, Ireland.
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23
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Moschini M, Fossati N, Sood A, Lee JK, Sammon J, Sun M, Pucheril D, Dalela D, Montorsi F, Karnes RJ, Briganti A, Trinh QD, Menon M, Abdollah F. Contemporary Management of Prostate Cancer Patients Suitable for Active Surveillance: A North American Population-based Study. Eur Urol Focus 2016; 4:68-74. [PMID: 28753764 DOI: 10.1016/j.euf.2016.06.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 05/21/2016] [Accepted: 06/02/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Active surveillance (AS) is increasingly recognized as a recommended treatment option for prostate cancer (PCa) patients with clinically localized, low-risk disease; however, previous studies suggested that its utilization is uncommon in the United States. OBJECTIVE We evaluated the nationwide utilization rate of AS in the contemporary era. DESIGN, SETTING, AND PARTICIPANTS We relied on the 2010-2011 Surveillance Epidemiology and End Results (SEER) database using all 18 SEER-based registries. We identified 9049 patients that fulfilled the University of California, San Francisco AS criteria (prostate-specific antigen level <10ng/ml, clinical T stage ≤2a, Gleason score ≤6 [no pattern 4 or 5], and percentage of positive biopsy cores <33%). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Logistic regression analysis tested the relationship between receiving local treatment and all available predictors. RESULTS AND LIMITATIONS Only 32% of AS candidates did not receive any active local treatment. This proportion varied widely among the SEER-based registries, ranging from 13% to 49% (p<0.001). In multivariable analyses, clinical stage T2a (odds ratio [OR]: 1.23; p=0.04) and percentage of positive cores (OR: 1.10 for each 2% increase; p<0.001) were associated with a higher probability of receiving local treatment. Conversely, older age (OR: 0.89 for each 2-yr increase; p<0.001), not being married (OR: 0.64; p<0.001), and uninsured status (OR: 0.55; p=0.008) were associated with a lower probability of receiving active local treatment. The study is limited by the fact that SEER does not distinguish among patients undergoing observation, AS, watchful waiting, or initial hormonal therapy. CONCLUSIONS In the United States, a considerable proportion of patients suitable for AS receive local treatment for PCa. Proportions differ significantly among SEER registries. PATIENT SUMMARY Having more extensive and palpable disease, having medical insurance, being married, and being younger are associated with an increased probability of receiving local treatment for low-risk prostate cancer.
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Affiliation(s)
- Marco Moschini
- Department of Urology, Vita Salute San Raffaele University, Milan, Italy; Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - Nicola Fossati
- Department of Urology, Vita Salute San Raffaele University, Milan, Italy; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Akshay Sood
- Vattikuti Urology Institute (VUI) and VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Hospital, Detroit, Detroit, MI, USA
| | - Justin K Lee
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jesse Sammon
- Vattikuti Urology Institute (VUI) and VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Hospital, Detroit, Detroit, MI, USA
| | - Maxine Sun
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
| | - Dan Pucheril
- Vattikuti Urology Institute (VUI) and VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Hospital, Detroit, Detroit, MI, USA
| | - Deepansh Dalela
- Vattikuti Urology Institute (VUI) and VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Hospital, Detroit, Detroit, MI, USA
| | - Francesco Montorsi
- Department of Urology, Vita Salute San Raffaele University, Milan, Italy
| | | | - Alberto Briganti
- Department of Urology, Vita Salute San Raffaele University, Milan, Italy
| | - Quoc-Dien Trinh
- Division of Urology and Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Mani Menon
- Vattikuti Urology Institute (VUI) and VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Hospital, Detroit, Detroit, MI, USA
| | - Firas Abdollah
- Vattikuti Urology Institute (VUI) and VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Hospital, Detroit, Detroit, MI, USA.
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