Quality of care received and patient-reported regret in prostate cancer: Analysis of a population-based prospective cohort

Association between adherence to radiation therapy quality metrics and patient reported outcomes in prostate cancer

BACKGROUND

Prior studies have shown significant variability in the quality of prostate cancer care in the US with questionable associations between quality measures and patient reported outcomes. We evaluated the impact of compliance with nationally recognized radiation therapy (RT) quality measures on patient-reported health-related quality of life (HRQOL) outcomes in the Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) cohort.

METHODS

CEASAR is a population-based, prospective cohort study of men with localized prostate cancer from which we identified 649 who received primary RT and completed HRQOL surveys for inclusion. Eight quality measures were identified based on national guidelines. We analyzed the impact of compliance with these measures on HRQOL assessed by the 26-item Expanded Prostate Index Composite at pre-specified intervals up to 5 years after treatment. Multivariable analysis was performed controlling for demographic and clinicopathologic features.

RESULTS

Among eligible participants, 566 (87%) patients received external beam radiation therapy and 83 (13%) received brachytherapy. Median age was 69 years (interquartile range: 64-73), 33% had low-, 43% intermediate-, and 23% high-risk disease. 28% received care non-compliant with at least one measure. In multivariable analyses, while some statistically significant associations were identified, there were no clinically significant associations between compliance with evaluated RT quality measures and patient reported urinary irritative, urinary incontinence, bowel, sexual or hormonal function.

CONCLUSIONS

Compliance with RT quality measures was not meaningfully associated with patient-reported outcomes after prostate cancer treatment. Further work is needed to identify patient-centered quality measures of prostate cancer care.

The Association Between Financial Toxicity and Treatment Regret in Men With Localized Prostate Cancer

BACKGROUND

Financial toxicity is emerging as an important patient-centered outcome and is understudied in prostate cancer patients. We sought to understand the association between financial burden and treatment regret in men with localized prostate cancer to better evaluate the role of financial discussions in patient counseling.

METHODS

Utilizing the Comparative Effectiveness Analysis of Surgery and Radiation dataset, we identified all men accrued between 2011 and 2012 who underwent surgery, radiation, or active surveillance for localized prostate cancer. Financial burden and treatment regret were assessed at 3- and 5-year follow-up. The association between financial burden and regret was assessed using multivariable longitudinal logistic regression controlling for demographic and disease characteristics, treatment, functional outcomes, and patient expectations.

RESULTS

Of the 2924 eligible patients, regret and financial burden assessments for 3- and/or 5-year follow-up were available for 81% (n = 2359). After adjustment for relevant covariates, financial burden from "finances in general" was associated with treatment regret at 3 years (odds ratio [OR] = 2.47, 95% confidence interval [CI] = 1.33 to 4.57; P = .004); however, this association was no longer statistically significant at 5-year follow-up (OR = 1.19, 95% CI = 0.56 to 2.54; P = .7).

CONCLUSIONS

In this population-based sample of men with localized prostate cancer, we observed associations between financial burden and treatment regret. Our findings suggest indirect treatment costs, especially during the first 3 years after diagnosis, may impact patients more profoundly than direct costs and are important for inclusion in shared decision making.

Association of Treatment Modality, Functional Outcomes, and Baseline Characteristics With Treatment-Related Regret Among Men With Localized Prostate Cancer

IMPORTANCE

Treatment-related regret is an integrative, patient-centered measure that accounts for morbidity, oncologic outcomes, and anxiety associated with prostate cancer diagnosis and treatment.

OBJECTIVE

To assess the association between treatment approach, functional outcomes, and patient expectations and treatment-related regret among patients with localized prostate cancer.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, prospective cohort study used 5 Surveillance, Epidemiology, and End Results (SEER)-based registries in the Comparative Effectiveness Analysis of Surgery and Radiation cohort. Participants included men with clinically localized prostate cancer from January 1, 2011, to December 31, 2012. Data were analyzed from August 2, 2020, to March 1, 2021.

EXPOSURES

Prostate cancer treatments included surgery, radiotherapy, and active surveillance.

MAIN OUTCOMES AND MEASURES

Patient-reported treatment-related regret using validated metrics. Regression models were adjusted for demographic and clinicopathologic characteristics, treatment approach, and patient-reported functional outcomes.

RESULTS

Among the 2072 men included in the analysis (median age, 64 [IQR, 59-69] years), treatment-related regret at 5 years after diagnosis was reported in 183 patients (16%) undergoing surgery, 76 (11%) undergoing radiotherapy, and 20 (7%) undergoing active surveillance. Compared with active surveillance and adjusting for baseline differences, active treatment was associated with an increased likelihood of regret for those undergoing surgery (adjusted odds ratio [aOR], 2.40 [95% CI, 1.44-4.01]) but not radiotherapy (aOR, 1.53 [95% CI, 0.88-2.66]). When mediation by patient-reported functional outcomes was considered, treatment modality was not independently associated with regret. Sexual dysfunction, but not other patient-reported functional outcomes, was significantly associated with regret (aOR for change in sexual function from baseline, 0.65 [95% CI, 0.52-0.81]). Subjective patient-perceived treatment efficacy (aOR, 5.40 [95% CI, 2.15-13.56]) and adverse effects (aOR, 5.83 [95% CI, 3.97-8.58]), compared with patient expectations before treatment, were associated with treatment-related regret. Other patient characteristics at the time of treatment decision-making, including participatory decision-making tool scores (aOR, 0.80 [95% CI, 0.69-0.92]), social support (aOR, 0.78 [95% CI, 0.67-0.90]), and age (aOR, 0.78 [95% CI, 0.62-0.97]), were significantly associated with regret. Results were comparable when assessing regret at 3 years rather than 5 years.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that more than 1 in 10 patients with localized prostate cancer experience treatment-related regret. The rates of regret appear to differ between treatment approaches in a manner that is mediated by functional outcomes and patient expectations. Treatment preparedness that focuses on expectations and treatment toxicity and is delivered in the context of shared decision-making should be the subject of future research to examine whether it can reduce regret.

A Systematic Review for Health Disparities and Inequities in Multiparametric Magnetic Resonance Imaging for Prostate Cancer Diagnosis

RATIONALE AND OBJECTIVES

Multi-parametric Magnetic Resonance Imaging (mpMRI) is a novel procedure recommended by the American Urological Association for Prostate Cancer (PCa) diagnosis. In radiology, differences in utilization of expensive screening techniques are described but never reviewed for mpMRI. Thus, our article aims at summarizing disparities relating to the expensive yet revolutionary mpMRI in United States men with PCa while highlighting needed research areas.

MATERIAL AND METHODS

Eligible articles were gathered via PubMed query, referred publications known to the authors or from the reference lists of the identified publications. We excluded studies that didn't specifically evaluate mpMRI technique, weren't conducted in the United States, or didn't directly assess the relationship between disparities and mpMRI. No date restrictions were applied, resulting articles were published through 2020.

RESULTS

Out of 80 publications, 17 were selected. Two unique themes were identified: 1) disparities in mpMRI utilization, and 2) performance. While demographic factors such as race, age and socioeconomic status played a significant role in utilization, mpMRI demonstrated equal and sometimes superior performance in AAs.

CONCLUSION

Our findings illustrate the importance of disparity awareness in PCa mpMRI and highlight the need to examine additional mpMRI disparities across other races and social determinants. A new area of inequity in PCa was theoretically illustrated, as lower utilization of mpMRI was detected in a group that could potentially benefit from it the most. Major limitation was the selected search terms. Our review is unique as disparities related to mpMRI were found to be multilayered, affecting utilization and performance. Continued research is needed to discover additional areas in efforts to reduce disparity gaps related to mpMRI and PCa.

Evolution of Disparities in Prostate Cancer Treatment: Is This a New Normal?

Despite notable screening, diagnostic, and therapeutic advances, disparities in prostate cancer incidence and outcomes remain prevalent. Although commonly discussed in the context of men of African descent, disparities also exist based on socioeconomic level, education level, and geographic location. The factors in these disparities span systemic access issues affecting availability of care, provider awareness, and personal patient views and mistrust. In this review, we will discuss common themes that patients have noted as impediments to care. We will review how equitable access to care has helped improve outcomes among many different groups of patients, including those with local disease and those with metastatic castration-resistant prostate cancer. Even with more advanced presentation, challenges with recommended screening, and lower rates of genomic testing and trial inclusion, Black populations have benefited greatly from various modalities of therapy, achieving comparable and at times superior outcomes with certain types of immunotherapy, chemotherapy, androgen receptor-based inhibitors, and radiopharmaceuticals in advanced disease. We will also briefly discuss access to genomic testing and differences in patterns of gene expression among Black patients and other groups that are traditionally underrepresented in trials and genomic cohort studies. We propose several strategies on behalf of providers and institutions to help promote more equitable care access environments and continued decreases in prostate cancer disparities across many subgroups.

Comparison of germline mutations in African American and Caucasian men with metastatic prostate cancer

BACKGROUND

The goal of this study is to evaluate germline genetic variants in African American men with metastatic prostate cancer as compared to those in Caucasian men with metastatic prostate cancer in an effort to understand the role of genetic factors in these populations.

METHODS

African American and Caucasian men with metastatic prostate cancer who had germline testing using multigene panels were used to generate comparisons. Germline genetic results, clinical parameters, and family histories between the two populations were analyzed.

RESULTS

A total of 867 patients were included in this retrospective study, including 188 African American and 669 Caucasian patients. There was no significant difference in the likelihood of a pathogenic or likely-pathogenic variants (PV/LPVs) between African American and Caucasian patients (p = .09). African American patients were more likely to have a variant of unknown significance than Caucasians (odds ratio [OR] = 1.95; p < .0001). BRCA1 PV/LPVs were higher in African Americans (OR = 4.86; p = .04). African American patients were less likely to have a PV/LPV in non-BRCA DNA repair genes (OR = 0.30; p = .008). Family history of breast (OR = 2.09; p = .002) or ovarian cancer (OR = 2.33; p = .04) predicted PV/LPVs in Caucasians but not African-Americans. This underscores the limitations of family history in AA men and the importance of personal history to guide germline testing in AA men.

CONCLUSIONS

In metastatic prostate cancer patients, PV/LPVs of tested genes did not vary by race, BRCA1 PV/LPVs were more common in the African American subset. However, PV/LPVs in non-BRCA DNA repair genes were less likely to be encountered in African Americans. Family history associated with genetic testing results in Caucasians only.

Health disparities and inequities in the utilization of diagnostic imaging for prostate cancer

PURPOSE

To review and summarize the reported health disparities and inequities in diagnostic imaging for prostate cancer.

METHODS

We queried the PubMed search engine for original publications studying disparate utilization of diagnostic imaging for prostate cancer. Query terms were as follows: prostate AND cancer AND diagnostic AND imaging AND (magnetic resonance imaging (MRI) OR computed tomography (CT) OR bone scintigraphy OR positron emission tomography (PET)-CT)) AND (inequities OR disparities OR socioeconomic OR race). Studies were included if they involved United States patients, had diagnostic imaging as a part of their care, and addressed health inequities.

RESULTS

A total of 104 studies were captured in the initial query with 17 meeting inclusion criteria, comprising 10 population-based analyses, 5 single institutional analyses, 1 multi-institutional analysis, and 1 review. Socioeconomic status and race were frequently associated with imaging utilization and guideline-concordant care. SEER analyses revealed that African-American men had higher odds of experiencing overuse of pelvic CT/pelvic MRI and bone scans, while older men experienced underuse. Higher income and younger age were more likely to receive imaging that was adherent to NCCN guidelines. African-American and Hispanic men were less likely than white men to receive prostate multiparametric MRI.

CONCLUSION

Race, age, and socioeconomic status play a significant role in the diagnostic management of prostate cancer. Certain demographics are more disparately affected and less likely to receive guideline-concordant care. Continued research and interventions are needed to ensure appropriate and accessible diagnostic imaging for prostate cancer and ultimately the delivery of quality and equitable care.

Leveraging Digital Data to Inform and Improve Quality Cancer Care

BACKGROUND

Efficient capture of routine clinical care and patient outcomes is needed at a population-level, as is evidence on important treatment-related side effects and their effect on well-being and clinical outcomes. The increasing availability of electronic health records (EHR) offers new opportunities to generate population-level patient-centered evidence on oncologic care that can better guide treatment decisions and patient-valued care.

METHODS

This study includes patients seeking care at an academic medical center, 2008 to 2018. Digital data sources are combined to address missingness, inaccuracy, and noise common to EHR data. Clinical concepts were identified and extracted from EHR unstructured data using natural language processing (NLP) and machine/deep learning techniques. All models are trained, tested, and validated on independent data samples using standard metrics.

RESULTS

We provide use cases for using EHR data to assess guideline adherence and quality measurements among patients with cancer. Pretreatment assessment was evaluated by guideline adherence and quality metrics for cancer staging metrics. Our studies in perioperative quality focused on medications administered and guideline adherence. Patient outcomes included treatment-related side effects and patient-reported outcomes.

CONCLUSIONS

Advanced technologies applied to EHRs present opportunities to advance population-level quality assessment, to learn from routinely collected clinical data for personalized treatment guidelines, and to augment epidemiologic and population health studies. The effective use of digital data can inform patient-valued care, quality initiatives, and policy guidelines.

IMPACT

A comprehensive set of health data analyzed with advanced technologies results in a unique resource that facilitates wide-ranging, innovative, and impactful research on prostate cancer. This work demonstrates new ways to use the EHRs and technology to advance epidemiologic studies and benefit oncologic care.See all articles in this CEBP Focus section, "Modernizing Population Science."

Development and pilot evaluation of a personalized decision support intervention for low risk prostate cancer patients

Objectives

Development and pilot evaluation of a personalized decision support intervention to help men with early‐stage prostate cancer choose among active surveillance, surgery, and radiation.

Methods

We developed a decision aid featuring long‐term survival and side effects data, based on focus group input and stakeholder endorsement. We trained premedical students to administer the intervention to newly diagnosed men with low‐risk prostate cancer seen at the University of California, San Francisco. Before the intervention, and after the consultation with a urologist, we administered the Decision Quality Instrument for Prostate Cancer (DQI‐PC). We hypothesized increases in two knowledge items from the DQI‐PC: How many men diagnosed with early‐stage prostate cancer will eventually die of prostate cancer? How much would waiting 3 months to make a treatment decision affect chances of survival? Correct answers were: “Most will die of something else” and “A little or not at all.”

Results

The development phase involved 6 patients, 1 family member, 2 physicians, and 5 other health care providers. In our pilot test, 57 men consented, and 44 received the decision support intervention and completed knowledge surveys at both timepoints. Regarding the two knowledge items of interest, before the intervention, 35/56 (63%) answered both correctly, compared to 36/44 (82%) after the medical consultation (P = .04 by chi‐square test).

Conclusions

The intervention was associated with increased patient knowledge. Data from this pilot have guided the development of a larger scale randomized clinical trial to improve decision quality in men with prostate cancer being treated in community settings.

Prevalence and predictors of probable depression in prostate cancer survivors

BACKGROUND

The early diagnosis and treatment of depression are cancer care priorities. These priorities are critical for prostate cancer survivors because men rarely seek mental health care. However, little is known about the epidemiology of depression in this patient population. The goal of this study was to describe the prevalence and predictors of probable depression in prostate cancer survivors.

METHODS

The data were from a population-based cohort of North Carolinian prostate cancer survivors who were enrolled from 2004 to 2007 in the North Carolina-Louisiana Prostate Cancer Project (n = 1031) and were prospectively followed annually from 2008 to 2011 in the Health Care Access and Prostate Cancer Treatment in North Carolina study (n = 805). Generalized estimating equations were used to evaluate an indicator of probable depression (Short Form 12 mental composite score ≤48.9; measured at enrollment and during the annual follow-up) as a function of individual-level characteristics within the longitudinal data set.

RESULTS

The prevalence of probable depression fell from 38% in the year of the cancer diagnosis to 20% 6 to 7 years later. Risk factors for probable depression throughout the study were African American race, unemployment, low annual income, younger age, recency of cancer diagnosis, past depression, comorbidities, treatment decisional regret, and nonadherence to exercise recommendations.

CONCLUSIONS

Depression is a major challenge for prostate cancer survivors, particularly in the first 5 years after the cancer diagnosis. To the authors' knowledge, this is the first study to demonstrate an association between treatment decisional regret and probable depression.

Patterns and predictors of self-reported clinical diagnosis and treatment for depression in prostate cancer survivors

Background

Appropriate depression care is a cancer‐care priority. However, many cancer survivors live with undiagnosed and untreated depression. Prostate cancer survivors may be particularly vulnerable, but little is known about their access to depression care. The goal of this study was to describe patterns and predictors of clinical diagnosis and treatment of depression in prostate cancer survivors.

Methods

Generalized estimating equations were used to evaluate indicators of self‐reported clinical diagnosis and treatment depression as a function of individual‐level characteristics within a longitudinal dataset. The data were from a population‐based cohort of North Carolinian prostate cancer survivors who were enrolled from 2004 to 2007 on the North Carolina‐Louisiana Prostate Cancer Project (N = 1,031), and prospectively followed annually from 2008 to 2011 on the Health Care Access and Prostate Cancer Treatment in North Carolina (N = 805).

Results

The average rate of self‐reported clinical diagnosis of depression was 44% (95% CI: 39%‐49%), which declined from 60% to 40% between prostate cancer diagnosis and 5‐7 years later. Factors associated with lower odds of self‐reported clinical diagnosis of depression include African‐American race, employment, age at enrollment, low education, infrequent primary care visits, and living with a prostate cancer diagnosis for more than 2 years. The average rate of self‐reported depression treatment was 62% (95% CI: 55%‐69%). Factors associated with lower odds of self‐reported depression treatment included employment and living with a prostate cancer diagnosis for 2 or more years.

Conclusion

Prostate cancer survivors experience barriers when in need of depression care.

The Detroit Research on Cancer Survivors (ROCS) Pilot Study: A Focus on Outcomes after Cancer in a Racially Diverse Patient Population

BACKGROUND

African Americans are often diagnosed with advanced stage cancer and experience higher mortality compared with whites in the United States. Contributing factors, like differences in access to medical care and the prevalence of comorbidities, do not entirely explain racial differences in outcomes.

METHODS

The Detroit Research on Cancer Survivors (ROCS) pilot study was conducted to investigate factors related to short- and long-term outcomes among patients with cancer. Participants completed web-based surveys, and mailed saliva specimens were collected for future genetic studies.

RESULTS

We recruited 1,000 participants with an overall response rate of 68%. Thirty-one percent completed the survey without any interviewer support and the remaining participated in an interviewer-administered survey. Seventy-four percent provided a saliva specimen and 64% consented for tumor tissue retrieval. African American survivors required more interviewer support (P < 0.001); however, their response rate (69.6%) was higher than non-Hispanic whites (65.4%). African Americans reported poorer overall cancer-related quality of life compared with non-Hispanic whites, measured by FACT-G score (P < 0.001), however, this relationship was reversed after controlling for socioeconomic factors, marital status, and the presence of comorbidities.

CONCLUSIONS

In this pilot study, we demonstrated that a web-based survey supplemented with telephone interviews and mailed saliva kits are cost-effective methods to collect patient-reported data and DNA for large studies of cancer survivors with a high proportion of minority patients. The preliminary data collected reinforces differences by race in factors affecting cancer outcomes. Our efforts continue as we expand this unique cohort to include more than 5,000 African American cancer survivors.

IMPACT

Formal investigation of factors influencing adverse outcomes among African American cancer survivors will be critical in closing the racial gap in morbidity and mortality.

Utilization of Prostate Cancer Quality Metrics for Research and Quality Improvement: A Structured Review

BACKGROUND

The shift toward value-based care in the United States emphasizes the role of quality measures in payment models. Many diseases, such as prostate cancer, have a proliferation of quality measures, resulting in resource burden and physician burnout. This study aimed to identify and summarize proposed prostate cancer quality measures and describe their frequency and use in peer-reviewed literature.

METHODS

The PubMed database was used to identify quality measures relevant to prostate cancer care, and included articles in English through April 2018. A gray literature search for other documents was also conducted. After the selection process of the pertinent articles, measure characteristics were abstracted, and uses were summarized for the 10 most frequently utilized measures in the literature.

RESULTS

A total of 26 articles were identified for review. Of the 71 proposed prostate cancer quality measures, only 47 were used, and less than 10% of these were endorsed by the National Quality Forum. Process measures were most frequently reported (84.5%). Only 6 outcome measures (8.5%) were proposed-none of which were among the most frequently utilized.

CONCLUSION

Although a high number of proposed prostate cancer quality measures are reported in the literature, few were assessed, and the majority of these were non-endorsed process measures. Process measures were most commonly assessed; outcome measures were rarely evaluated. In a step to close the quality chasm, a "top 5" core set of quality measures for prostate cancer care, including structure, process, and outcomes measures, is suggested. Future studies should consider this comprehensive set of quality measures.

Technical Feasibility of Tissue Microarray (TMA) Analysis of Tumor-Associated Immune Response in Prostate Cancer

Introduction: The androgen receptor (AR) regulates immune-related epithelial-to-mesenchymal transition (EMT), and prostate cancer (PCa) metastasis. Primary tumor-infiltrating lymphocytes (TILs) [CD3⁺, CD4⁺, and CD8⁺ TILs] are potential prognostic indicators in PCa, and variations may contribute to racial disparities in tumor biology and PCa outcomes.

Aim: To assess the technical feasibility of tumor microarray (TMA)-based methods to perform multi-marker TIL profiling in primary resected PCa.

Methods: Paraffin-embedded tissue cores of histopathologically-confirmed primary PCa (n = 40; 1 TMA tissue specimen loss) were arrayed in triplicate on TMAs. Expression profiles of AR, CD3⁺, CD4⁺, and CD8⁺ TILs in normal prostate, and the center and periphery of both the tumor-dominant nodule and highest Gleason grade were detected by IHC and associated with clinical and pathological data using standard statistical methodology. An independent pathologist, blinded to the clinical data, scored all samples (percent and intensity of positive cells).

Results: TMAs were constructed from 21 (53.8%) Black and 18 (46.2%) White males with completely-resected, primarily pT2 stage PCa [pT2a (n = 3; 7.7%); pT2b (n = 2; 5.1%); pT2c (n = 27; 69.2%); pT3a (n = 5; 12.8%); mean pre-op PSA = 8.17 ng/ml]. The CD3, CD4, CD8, and CD8/CD3 cellular protein expression differed from normal in the periphery of the dominant nodule, the center of the highest Gleason grade, and the periphery of the highest Gleason grade (P < 0.05). Correlations between TIL expression in the center and periphery of the dominant nodule, with corresponding center and periphery of the highest Gleason grade, respectively, were robust, and the magnitude of these correlations differed markedly by race (P < 0.05).

Conclusions: Multi-marker (AR, CD3, CD4, CD8) profiling with IHC analysis of TMAs consisting of primary, non-metastatic resected prostate cancer is technically feasible in this pilot study. Future studies will evaluate primary tumor immunoscore using semi-quantitative, IHC-based methodology to assess differences in the spectrum, quantity, and/or localization of TILs, and to gain insights into racial disparities in PCa tumor biology and clinical outcomes.

Making their decisions for prostate cancer treatment: Patients' experiences and preferences related to process

INTRODUCTION

We sought to determine the experiences and preferences of prostate cancer patients related to the process of making their treatment decisions, and to the use of decision support.

METHODS

Population surveys were conducted in four Canadian provinces in 2014-2015. Each provincial cancer registry mailed surveys to a random sample of their prostate cancer patients diagnosed in late 2012. Three registries' response rates were 46-55%; the fourth used a different recruiting strategy, producing a response rate of 13% (total n=1366).

RESULTS

Overall, 90% (n=1113) of respondents reported that they were involved in their treatment decisions. Twenty-three percent (n=247) of respondents wanted more help with the decision than they received and 52% of them (n=128) reported feeling well-informed. Only 51% (n=653) of all respondents reported receiving any decision support, but an additional 34% (n=437) would want to if they were aware of its existence. A quarter (25%, n=316) of respondents found it helpful to use a decision aid, a type of decision support that provides assistance to decision processes and provides information, but 64% (n=828) reported never having heard of decision aids; 26% (n=176) of those who had never heard of decision aids wanted more help with the decision than they received compared to 13% (n=36) of those who had used a decision aid.

CONCLUSIONS

The majority of respondents wanted to participate in their treatment decisions, but a portion wanted more help than they received. Half of those who wanted more help felt well-informed, thus, needed support beyond information. Decision aids have potential to provide information and support to the decision process.

Quality of care and economic considerations of active surveillance of men with prostate cancer

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.

African-American men and prostate cancer-specific mortality: a competing risk analysis of a large institutional cohort, 1989-2015

Significant racial disparities in prostate cancer (PCa) outcomes have been reported, with African-American men (AAM) more likely to endure adverse oncologic outcomes. Despite efforts to dissipate racial disparities in PCa, a survival gap persists and it remains unclear to what extent this disparity can be explained by known clinicodemographic factors. In this study, we leveraged our large institutional database, spanning over 25 years, to investigate whether AAM continued to experience poor PCa outcomes and factors that may contribute to racial disparities in PCa. A total of 7307 patients diagnosed with PCa from 1989 through 2015 were included. Associations of race and clinicodemographic characteristics were analyzed using chi-square for categorical and Mann-Whitney U-test for continuous variables. Racial differences in prostate cancer outcomes were analyzed using competing risk analysis methods of Fine and Gray. Median follow-up time was 106 months. There were 2304 deaths recorded, of which 432 resulted from PCa. AAM were more likely to be diagnosed at an earlier age (median 60 vs. 65 years, P = <0.001) and were more likely to have ≥1 comorbidities (13.6% vs. 7.5%, P < 0.001). In a multivariate competing risk model, adjusted for baseline covariates, AAM experienced significantly higher risk of PCSM compared to NHW men (HR, 1.62, 95% CI, 1.02-2.57, P = 0.03) NHW. Among men diagnosed at an older age (>60 years), racial differences in PCSM were more pronounced, with AAM experiencing higher rates of PCSM (HR, 2.05, 95% CI, 1.26-3.34, P = 0.003). After adjustment of clinicodemographic and potential risk factors, AAM continue to experience an increased risk of mortality from PCa, especially older AAM. Furthermore, AAM are more likely to be diagnosed at an early age and more likely to have higher comorbidity indices.

Urinary Incontinence, Patient Satisfaction, and Decisional Regret after Prostate Cancer Treatment: A French National Study

BACKGROUND

Complications of prostate cancer treatments have a substantial impact on the patient's quality of life. We evaluated the prevalence of urinary consequences and factors affecting patient satisfaction and decisional regret after treatment.

METHODS

A retrospective self-administered questionnaire was sent to all members of the National Association of Prostate Cancer Patients in France.

RESULTS

From the 226 completed questionnaires received, the following information was obtained: 110 patients underwent surgery only, 29 received radiotherapy plus hormone therapy, 28 received radiotherapy only, and 49 received other combination treatments. The median follow-up period was 58.1 months. After treatment, the presence of urinary incontinence was reported by 34.5% of patients treated by radical prostatectomy, by 10.3% treated by radiotherapy plus hormone therapy, by 17.8% treated by curitherapy or radiotherapy only, and by 38.7% treated by other combination therapy (p = 0.01). The main reasons for decisional regret were the fact that patients received incomplete information about prostate cancer (40%) and consequences of treatment that affected the urinary system (34%). The information received about cancer was considered complete in 32.3% of the satisfied group and 14.3% of the decisional regret group (p = 0.003) and with regard to urinary incontinence the information received was considered complete in 41.4 and 17.4% respectively (p < 0.01).

CONCLUSIONS

Urinary consequences of prostate cancer treatment are common and impact the quality of life. Patients need clear information to be able to participate in therapeutic decision-making and to avoid subsequent decisional regret.

[Why and how to promote decision-making autonomy of cancer patients?]

Involvement of patients in decision-making about their health has been promoted nationally and internationally since several years. Despite this, patient (and their relatives) participation remains insufficient and one of the objectives of the current French national cancer policy (Plan cancer 2014-2019) is to give everyone the possibility to play an active role in the management of their care. This overview focuses on decision-making autonomy of cancer patients through two main questions: why and how to promote it? After a brief review of the decision-making models described in the literature in the past decades insisting on the major role of the decisional context and the dynamic character of this context, this article presents a selection of published works which aimed to respond to those 2 questions.

Need of informatics in designing interoperable clinical registries

Clinical registries are designed to collect information relating to a particular condition for research or quality improvement. Intuitively, informatics in the area of data management and extraction plays a central role in clinical registries. Due to various reasons such as lack of informatics awareness or expertise, there may be little informatics involvement in designing clinical registries. In this paper, we studied a clinical registry from two critical perspectives, data quality and interoperability, where informatics can play a role. We evaluated these two aspects of an existing registry, Gynecology Surgery Registry, by mapping data elements and value sets, used in the registry, to a standardized terminology, SNOMED-CT. The results showed that majority of the values are ad-hoc and only 6 of 91 procedures in the registry could be mapped to the SNOMED-CT. To tackle this issue, we assessed the feasibility of automated data abstraction process, by training machine learning classifiers, based on existing manually extracted data. These classifiers achieved a reasonable average F-measure of 0.94. We concluded that more informatics engagement is needed to improve the interoperability, reusability, and quality of the registry.

African-American Prostate Cancer Disparities

PURPOSE OF REVIEW

The purpose of this review is to examine prostate cancer racial disparities specific to the African-American population.

RECENT FINDINGS

African-American men are more likely to be diagnosed with prostate cancer, present at an earlier age; are more likely to have locally advanced or metastatic disease at diagnosis; and have suboptimal outcomes to standard treatments. Prostate cancer treatment requires a nuanced approach, particularly when applying screening, counseling, and management of African-American men. Oncological as well as functional outcomes may differ and are potentially due to a combination of genetic, molecular, behavioral, and socioeconomic factors.

The pervasive crisis of diminishing radiation therapy access for vulnerable populations in the United States, part 1: African-American patients

Introduction

African Americans experience the highest burden of cancer incidence and mortality in the United States and have been persistently less likely to receive interventional care, even when such care has been proven superior to conservative management by randomized controlled trials. The presence of disparities in access to radiation therapy (RT) for African American cancer patients has rarely been examined in an expansive fashion.

Methods and materials

An extensive literature search was performed using the PubMed database to examine studies investigating disparities in RT access for African Americans.

Results

A total of 55 studies were found, spanning 11 organ systems. Disparities in access to RT for African Americans were most prominently study in cancers of the breast (23 studies), prostate (7 studies), gynecologic system (5 studies), and hematologic system (5 studies). Disparities in RT access for African Americans were prevalent regardless of organ system studied and often occurred independently of socioeconomic status. Fifty of 55 studies (91%) involved analysis of a population-based database such as Surveillance, Epidemiology and End Result (SEER; 26 studies), SEER-Medicare (5 studies), National Cancer Database (3 studies), or a state tumor registry (13 studies).

Conclusions

African Americans in the United States have diminished access to RT compared with Caucasian patients, independent of but often in concert with low socioeconomic status. These findings underscore the importance of finding systemic and systematic solutions to address these inequalities to reduce the barriers that patient race provides in receipt of optimal cancer care.

Determinants of patient activation in a community sample of breast and prostate cancer survivors

BACKGROUND

Patient activation-the knowledge, skills, and confidence to manage one's health-is associated with improved self-management behaviors for several chronic conditions. This study assesses rates of patient activation in breast and prostate cancer survivors and explores the characteristics associated with patient activation.

METHODS

A cross-sectional study of survivors with localized (Stage I or II) breast and prostate cancers who were post-treatment (between 1-10+ years) were recruited from 4 community hospital sites in New Jersey. Survey data on patient characteristics (demographic and psychosocial) and clinical factors were assessed to explore the relationships with patient activation using the Patient Activation Measure-13.

RESULTS

Among 325 survivors (112 prostate; 213 breast), overall patient activation was high (M = 3.25). Activation was significantly lower among prostate survivors when compared with breast cancer survivors (M = 3.25 [SD, 0.38] vs M = 3.34 [SD, 0.37], P<.05). For prostate survivors, race (P < .05), marital status (P < .001), employment status (P < .01), household income (P < .05), and fear of recurrence (P < .01) were significantly associated with patient activation. For both groups, ease of access to oncology team and primary care physicians (PCPs) (all P values < .001) and perceptions of time spent with oncologists' team and PCPs (all P values < .01) were positive predictors of activation.

CONCLUSIONS

In both breast and prostate survivors, access to providers (both PCPs and oncologists) and perception that adequate time spent with providers were associated with activation. Therefore, clinical interventions maybe a promising avenue to improve patient activation. Research is needed to develop and test tailored patient activation interventions to improve self-management among cancer survivors.

Influence of Age on Guideline-Concordant Cancer Care for Elderly Patients in the United States

PURPOSE

To examine the frequency of guideline-concordant cancer care in elderly patients, including "older" elderly (age ≥80 years).

METHODS AND MATERIALS

Using the Surveillance, Epidemiology and End Results-Medicare dataset in patients aged ≥66 years diagnosed with nonmetastatic breast cancer (n=55,094), non-small cell lung (NSCLC) (n=36,203), or prostate cancer (n=86,544) from 2006 to 2011, chemotherapy, surgery, and radiation (RT) treatments were identified using claims. Pearson χ² tested associations between age and guideline concordance.

RESULTS

Older patients were less likely to receive guideline-concordant curative treatment: in stage III breast cancer, receipt of postmastectomy RT (70%, 46%, and 21% in patients aged 66-79, 80-89, and ≥90 years, respectively; P<.0001); in stage I NSCLC, RT or surgery (89%, 80%, and 64% in age 66-79, 80-89, and ≥90 years; P<.0001); in stage III NSCLC, RT or surgery plus chemotherapy (79%, 58%, and 27% in age 66-79, 80-89, and ≥90 years; P<.0001); and in intermediate/high-risk prostate cancer, RT or prostatectomy (projected life expectancy >10 years: 85% and 82% in age 66-69 and 70-75 years; and ≤10 years: 70%, 42%, and 9% in age 76-79, 80-89, and ≥90 years; P<.0001). However, older patients were more likely to receive guideline-concordant de-intensified treatment: in stage I to II node-negative breast cancer, hypofractionated postlumpectomy RT (9%, 16%, and 23% in age 66-79, 80-89, and ≥90 years; P<.0001); in stage I estrogen receptor-positive breast cancer, observation after lumpectomy (12%, 42%, and 84% in age 66-79, 80-89, and ≥90 years; P<.0001); in stage I NSCLC, stereotactic body RT instead of surgery (7%, 16%, and 25% in age 66-79, 80-89, and ≥90 years; P<.0001); and in lower-risk prostate cancer, no active treatment (25%, 54%, and 68% in age 66-79, 80-89, and ≥90 years; P<.0001).

CONCLUSION

Actual treatment of older elderly cancer patients frequently diverged from guidelines, especially in curative treatment of advanced disease. Results suggest a need for better metrics than existing guidelines alone to evaluate quality and appropriateness of care in this population.