Risk of Secondary Malignancies After Pelvic Radiation: A Population-based Analysis

Background and objective

Radiation therapy has increasingly been used in the management of pelvic malignancies. However, the use of radiation continues to pose a risk of a secondary malignancy to its recipients. This study investigates the risk of secondary malignancy development following radiation for primary pelvic malignancies.

Methods

A retrospective cohort review of the Surveillance, Epidemiology, and End Results database from 1975 to 2016 was performed. Primary pelvic malignancies were subdivided based on the receipt of radiation, and secondary malignancies were stratified as pelvic or nonpelvic to investigate the local effect of radiation.

Key findings and limitations

A total of 2 102 192 patients were analyzed (1 189 108 with prostate, 315 026 with bladder, 88 809 with cervical, 249 535 with uterine, and 259 714 with rectal/anal cancer). The incidence rate (defined as cases per 1000 person years) of any secondary malignancies (including but not limited to secondary pelvic malignancies) was higher in radiation patients than in nonradiation patients (incidence rate ratio [IRR] 1.04, confidence interval [CI] 1.03-1.05), with significantly greater rates noted in radiation patients with prostate (IRR 1.22, CI 1.21-1.24), uterine (IRR 1.34), and cervical (IRR 1.80, CI 1.72-1.88) cancer. While the overall incidence rate of any secondary pelvic malignancy was lower in radiation patients (IRR 0.79, CI 0.78-0.81), a greater incidence was still noted in the same cohorts including radiation patients with prostate (IRR 1.42, CI 1.39-1.45), uterine (IRR 1.15, CI 1.08-1.21), and cervical (IRR 1.72, CI 1.59-1.86) cancer.

Conclusions and clinical implications

Except for localized cervical cancer, when put in the context of median overall survival, the impact of radiation likely does not carry enough weight to change practice patterns. Radiation for pelvic malignancies increases the risk for several secondary malignancies, and more specifically, secondary pelvic malignancies, but with a relatively low absolute risk of secondary malignancies, the benefits of radiation warrant continued use for most pelvic malignancies. Practice changes should be considered for radiation utilization in malignancies with excellent cancer-specific survival such as cervical cancer.

Patient summary

The use of radiation for the management of pelvic malignancies induces a risk of secondary malignancies to its recipients. However, the absolute risk being low, the benefits of radiation warrant its continued use, and a change in practice patterns is unlikely.

Trends in Emergency Department Admissions Due to Renal Colic in the Pediatric Population: A Multicenter Study

BACKGROUND

Pediatric urolithiasis is relatively uncommon and is generally associated with predisposing anatomic or metabolic abnormalities. In the adult population, emergency department (ED) admissions have been associated with an increase in ambient temperature. The same association has not been evaluated in the pediatric population.

OBJECTIVES

To analyze trends in ED admissions due to renal colic in a pediatric population (≤ 18 years old) and to assess the possible effect of climate on ED admissions.

METHODS

We conducted a retrospective, multicenter cohort study, based on a computerized database of all ED visits due to renal colic in pediatric patients. The study cohort presented with urolithiasis on imaging during their ED admission. Exact climate data was acquired through the Israeli Meteorological Service (IMS).

RESULTS

Between January 2010 and December 2020, 609 patients, ≤ 18 years, were admitted to EDs in five medical centers with renal colic: 318 males (52%), 291 females (48%). The median age was 17 years (IQR 9-16). ED visits oscillated through the years, peaking in 2012 and 2018. A 6% downward trend in ED admissions was noted between 2010 and 2020. The number of ED admissions in the different seasons was 179 in autumn (30%), 134 in winter (22%), 152 in spring (25%), and 144 in summer (23%) (P = 0.8). Logistic regression multivariable analysis associated with ED visits did not find any correlation between climate parameters and ED admissions due to renal colic in the pediatric population.

CONCLUSIONS

ED admissions oscillated during the period investigated and had a downward trend. Unlike in the adult population, rates of renal colic ED admissions in the pediatric population were not affected by seasonal changes or rise in maximum ambient temperature.

Disparities Associated with Shared Decision-making in Prostate Cancer Screening

BACKGROUND

Prostate cancer screening guidelines recommend shared decision-making (SDM) regarding prostate-specific antigen (PSA) testing. However, it is unclear who undergoes SDM and whether any disparities exist.

OBJECTIVE

To examine sociodemographic differences in participation of SDM and its association with PSA testing in prostate cancer screening.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cross-sectional study was conducted among men aged 45-75 yr undergoing PSA screening, using the 2018 National Health Interview Survey database. The evaluated sociodemographic features included age, race, marital status, sexual orientation, smoking status, working status, financial difficulty, US geographic regions, and cancer history. Questions regarding self-reported PSA testing and whether respondents discussed its advantages and disadvantages with their healthcare provider were analyzed.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Our primary outcome was to evaluate the possible associations between various sociodemographic factors and undergoing PSA screening and SDM. We used multivariable logistic regression analyses to detect potential associations.

RESULTS AND LIMITATIONS

A total of 59596 men were identified, of whom 5605 answered the question regarding PSA testing, with 2288 (40.6%) undergoing PSA testing. Of these men, 39.5% (n = 2226) discussed the advantages and 25.6% (n = 1434) discussed the disadvantages of PSA testing. On a multivariable analysis, older (odds ratio [OR] 1.092; 95% confidence interval [CI] 1.081-1.103, p < 0.001) and married (OR 1.488; 95% CI 1.287-1.720, p < 0.001) men were more likely to undergo PSA testing. Although Black men were more likely to discuss PSA advantages (OR 1.421; 95% CI 1.150-1.756, p = 0.001) and disadvantages (OR 1.554; 95% CI 1.240-1.947, p < 0.001) than White men, this did not correlate with higher rates of PSA screening (OR 1.086; 95% CI 0.865-1.364, p = 0.477). The lack of important clinical data remains a limitation.

CONCLUSIONS

Overall, SDM rates were low. Older and married men had an increased likelihood of SDM and PSA testing. Despite higher rates of SDM, Black men had similar rates of PSA testing to White men.

PATIENT SUMMARY

We evaluated sociodemographic differences in shared decision-making (SDM) in prostate cancer screening using a large national database. We found that SDM had varying results in different sociodemographic groups.

Effect of gender on presentation and outcome of renal colic

OBJECTIVES

To examine gender-related differences in the presentation, management, and outcomes of patients admitted to the emergency department ED with ureteral stones.

METHODS

Retrospective analysis of all patients admitted to the ED at our institution, found to have a ureteral stone on CT. Clinical, laboratory, imaging parameters, and outcomes were collected.

RESULTS

778 patients were admitted with ureteral stones between January 2018 and December 2020. 78% (n = 609) were males and 22% (n = 169) were females. The mean ages were 49.4 (SD 14.4) and 51.6 (SD 15.7) in males and females, respectively (p = 0.08). Female patients presented with a higher body temperature (p = 0.01), pulse rate (p < 0.0001), nausea and vomiting (p < 0.0001), elevated serum C-reactive protein (CRP) (p = 0.002) compared to males. The prevalence of elevated serum creatinine was higher in males (p < 0.0001). Alpha-blockers were recommended on discharge in 54.8% (334) of males, compared to only 29.6% (50) of females (p < 0.0001). Spontaneous stone expulsion was significantly higher in males compared to females (p = 0.01).

CONCLUSIONS

Our results demonstrate that gender does effect presentation and outcome of patients presenting with renal colic. Females were found to have elevated infectious parameters, more nausea and vomiting and a higher incidence of positive urine cultures. Males admitted to the ED were found to have significantly higher serum creatinine levels. Medical expulsive therapy (MET) with alpha-blockers was prescribed significantly less in female patients, which may have resulted in a lower spontaneous stone expulsion rate.

Metastatic Testicular Cancer Patterns and Predictors: A Contemporary Population-based SEER Analysis

OBJECTIVE

To elucidate clinical and demographic predictors of metastatic testicular cancer (TC) at presentation and study the impact of these factors on prognosis. Patients with metastatic TC experience poorer outcomes than those with localized or locoregional disease. Social determinants of health may compound this trend.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was queried to identify 16,528 patients aged ≥18 with TC diagnosed from 2010 to 2016. Descriptive statistics were analyzed using Fisher exact test and Pearson chi-square test for continuous and categorical variables. Predictors of specific metastases and factors impacting cancer-specific mortality (CSM) were evaluated using multivariate logistic regression analysis and competing risks regression, respectively.

RESULTS

Of 16,474 patients with complete data, 1877 (11.39%) had distant metastases at diagnosis. These patients more commonly featured disease-specific and demographic variables associated with worse health outcomes (all P < .001). Lung metastases were the predominant site of synchronous and solitary metastases. Disease-specific predictors of metastasis included T stage, histology, tumor size, lymphovascular invasion, and cryptorchidism. Patient-specific predictors included age, geography, ethnicity, race, marital status, and socioeconomic status. Nearly one-fourth of patients with metastases died. Poor CSM was predicted by histology, age, insurance status, and socioeconomic status. All metastatic sites except bone were associated with worse CSM, with lung metastases conferring the greatest risk.

CONCLUSION

This cross-sectional study identifies variables associated with TC metastasis and survival, particularly highlighting the importance of social determinants of health in TC mortality. These findings can facilitate a risk-stratified approach to staging and management while supporting new approaches to target disparities.

Post-operative pain following percutaneous nephrolithotripsy- clinical correlates

OBJECTIVES

Management of postoperative pain following percutaneous nephrolithotripsy (PCNL) is a significant goal. We sought to identify risk factors and clinical correlates of postoperative pain in order to improve perioperative management and patient satisfaction.

MATERIALS AND METHODS

A single-center, retrospective analysis, from a prospectively maintained database, of all consecutive patients who underwent PCNL for renal calculi between January 2011 and August 2018. Postoperative pain was assessed using the visual analog scale (VAS) and analgesic use. We considered VAS score above 4 as meaningful. Pain management was standardized according to patirnt reported VAS scores. Multivariable logistic regression was performed to identify risk factors and clinical correlates.

RESULTS

A total of 496 patients were analyzed. Younger age was associated with VAS above 4 on the operative day and the first postoperative following PCNL (p = 0.003 and p < 0.001, respectively). Female gender was associated with VAS above 4 in the first 2 days following the operation (p < 0.001).

CONCLUSIONS

Younger age and female gender would most likely benefit from pre-emptive improved pain management protocols following PCNL.

Does a prior cancer diagnosis impact PSA testing? Results from the National Health Interview Survey

INTRODUCTION

Prostate-specific antigen (PSA) testing remains a controversial issue. However, most urological guidelines recommend PSA testing in men aged 55-69 through a shared decision-making process with the patient. The impact of prior cancer diagnosis on PSA testing is not well-known. To compare PSA testing in men aged 55-69 years with and without a history of cancer (excluding prostate cancer patients).

MATERIALS AND METHODS

Utilizing the National Health Interview Survey (NHIS), a retrospective cross-sectional study during the year 2018 was carried out. Multivariable logistic regression analysis was implemented to demonstrate potential associations with PSA testing and assess the association of cancer history.

RESULTS

A total of 2,892 men aged 55-69 years from the NHIS survey who met the inclusion criteria were analyzed. A total of 308 (10.7%) men had a history of cancer (non-prostate). Men with a cancer history had a higher number of PSA tests and more recent testing than men with no previous cancer history. On multivariable analysis, men who were previously diagnosed with cancer had a higher likelihood of undergoing PSA testing compared to men with no history of cancer (OR: 1.87, 95% CI 1.39-2.52, p < 0.0001).

CONCLUSIONS

Our data suggest that men aged 55-69 with a history of cancer are more likely to undergo PSA testing than men with no cancer history.

The Current Role of Lymph Node Dissection in Nonmetastatic Localized Renal Cell Carcinoma

PURPOSE

To explore the current role of lymph node dissection (LND) in the management of nonmetastatic localized renal cell carcinoma (RCC).

BACKGROUND

There is currently no proven benefit of LND in the setting of RCC, and its role remains controversial because of conflicting evidence. Patients who may benefit from LND are those at greatest risk of nodal disease, but the tools used to predict nodal involvement are limited due to unpredictable retroperitoneal lymphatics. The indications, templates, and extent of LND are also not standardized, adding to the ambiguity of current guidelines surrounding its use.

EVIDENCE ACQUISITION

A PubMed search of the literature from January 2017 to December 2022 was conducted using the search terms "renal cell carcinoma" or "renal cancer" in combination with "lymph node dissection" or "lymphadenectomy". Case studies and editorials were excluded, whereas studies investigating the therapeutic effect of LND were classified as either demonstrating a benefit or no benefit. References of the studies and review articles were also searched for notable studies and findings that were outside the five-year literature search. The studies in this review were restricted to the English language.

RESULTS

Only a number of studies in recent years have found an association between the extent of LND and increased survival. Most studies do not indicate an associated benefit, and some even suggest a negative effect on survival. Most of these studies are retrospective.

CONCLUSION

The therapeutic value of LND in RCC is still unclear, and although prospective data are needed, its declining rates and emerging new therapies make this unlikely. A better understanding of renal lymphatics and improved detection of nodal disease may help determine the role of LND in nonmetastatic localized RCC.

Age related differences in primary testicular lymphoma: A population based cohort study

INTRODUCTION

Primary testicular non-Hodgkin's lymphoma (PTL) is a very rare disease, comprising 1% of all non-Hodgkin's lymphoma and <5% of all cases of testicular tumors. With a median age at diagnosis of 67 years, PTL is the most common testicular malignancy in men aged >60 years. There is limited published data on PTL incidence and outcomes in younger patients. The aim of this study is to compare the clinical parameters and survival outcomes between the patients older and younger than 50.

METHODS

The SEER database was queried for all patients diagnosed with PTL between 1983 and 2017. Data collected consisted of demographic, and clinical parameters, including staging, pathological assessments, and survival data. Patients were stratified according to their age and compared.

RESULTS

There was a total of 1,581 patients diagnosed with PTL between the year 2000 and 2017, of whom 215 (13.6%) were younger than 50 years old. The median age at diagnosis was 41 (interquartile range [IQR] 1-50), and 72 (IQR 51-95) years old for patients ≤50 and patients > 50 years of age, respectively. Comparison of younger and older patients detected similarities in disease laterality (92% vs. 94%, P = 0.38) and Ann Arbor stage I to II at diagnosis (76% vs. 75%, P = 0.59). The most common diffuse large B-cell lymphoma (DLBCL) subtype was more common in older patients (61% vs. 87%, P < 0.001). Radical orchiectomy (71% vs. 79%, P = 0.004) and radiation treatment (40% vs. 37%, P = 0.49) rates were comparable between both groups. However, a higher proportion of younger patients underwent chemotherapy (83% vs. 72%, P < 0.001). Patients ≤50 and >50 years old had a hazard ratio (HR) of 0.63 (95% CI: 0.57-0.71) and 0.34 (95% CI: 0.31-0.37), respectively, for 10-year OS with a median survival time for patients >50 of 5.75 years (95% CI: 5.25-6.33), P < 0.001. Patients ≤50 years old had a HR of 0.33 (95% CI: 0.26-0.40) compared to HR of 0.40 (95% CI: 0.37-0.43) in patients >50 years old for cumulative disease-specific mortality (DSM, P = 0.0204). Age >50 years was associated with worse DSM with a HR of 1.39 (95% CI: 1.05- 1.86, P = 0.024). Ann Arbor stage II and higher was also associated with worse DSM, while undergoing surgery, radiotherapy, and chemotherapy were associated with improved DSM.

CONCLUSIONS

PTL is the most common testicular malignancy in men older than 60 years of age, but more than a quarter of the patients are younger than 60 and more than 13% are ≤50 years. Younger patients are more likely to receive chemotherapy and radiation, and overall do better in terms of DSM. Being younger, having a lower Ann Arbor stage and being treated with chemotherapy and radiotherapy increase the chances of survival.

Predicting perioperative complications for partial versus radical nephrectomy in T1b-T2 renal cell carcinoma

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Background: The standard of care for larger localized RCC lesions is radical (RN) or partial (PN) nephrectomy. RN is increasingly utilized to maximize oncologic benefit in complex tumors. Although PN is a more technically complex procedure, its nephron-sparing nature confers lasting renal and cardiovascular benefits. We utilized the National Surgical Quality Improvement Program (NSQIP) database to elucidate predictors of perioperative morbidity in T1b-T2 RCC patients. Methods: Using the NSQIP Nephrectomy-Targeted PUF, 2,094 patients undergoing nephrectomy between 2019-2020 for localized T1b-T2 RCC were identified. Variables of interest included surgical procedure and approach, tumor stage, demographics, pre-operative laboratory values, comorbidities, infection and venothromboembolism (VTE) prophylaxis techniques, peri-operative complications, operative time, length of hospital stay, 30-day reoperations, and 30-day readmissions. Chi square test was used to analyze univariate associations between certain comorbidities and complications. Multivariate regression analysis was utilized to compare complication rates between PN and RN after adjusting for baseline characteristics and surgical approach. p<0.05 was considered statistically significant. Results: 816 patients received PN while 1,278 received RN. PN patients had an increase in the following events: 30-day readmissions (7.0% vs. 4.7%, p=0.026), major bleeds (9.19% vs. 5.56%, p=0.001), renal failure requiring dialysis (1.23% vs. 0.31%, p=0.013), and urine leak or ureteric fistulae (1.10% vs. 0.31%, p=0.025). Open surgery was associated with increased VTE, renal failure, bleeds, urine leaks or ureteric fistulae, readmissions, and reoperations. Multivariate analysis revealed that PN remained predictive of all four aforementioned events, although further adjustment for robotic approach led to a loss of significance for renal failure and ureteric fistulae. Additional patient-specific predictors of relevant complications across procedure type included bleeding disorder and dialysis for bleeds, and renal failure, steroid use, and COPD for readmissions. Conclusions: This is the first study to evaluate the new NSQIP Nephrectomy-Targeted PUF. This population-based cohort provides unique insights into nephrectomy for pT1b-T2 localized RCC. We demonstrate significant associations between PN and specific complications, modulated by particular comorbidities, although both PN and RN were exceedingly safe. This analysis supports the development of novel risk stratification tools which account for specific patient comorbidities in predicting near term risk. Improved understanding of case-specific determinants of morbidity following PN or RN may facilitate shared decision making in localized RCC management.

Novel synthetic lethality drug target in urothelial bladder cancer based on MTAP genomic loss

BACKGROUND

When urothelial carcinoma of the bladder (UCB) presents or progresses to chemo-refractory metastatic disease, the search for new therapeutic targets is paramount. Targeting protein arginine methyltransferase 5 accumulation in tumors with methylthioadenosine phosphorylase (MTAP) genomic loss has been proposed as a new anti-tumor strategy. We evaluated the incidence of patients with MTAP loss and correlate to treatment-guiding targets and biomarkers.

METHODS

Two thousand six hundred eighty-three cases of advanced UCB underwent hybrid-capture based comprehensive genomic profiling using the FDA-approved F1CDx assay to evaluate all classes of genomic alterations (GA) among 324 genes. Tumor mutational burden was determined on at least 0.8 Mbp of sequenced DNA and microsatellite instability was determined on at least 95 loci.

RESULTS

650 (24%) of UCB featured MTAP loss mutations (MTAP-). The gene and age distributions were similar in MTAP intact (MTAP+) and MTAP- UCB. MTAP- UCB contained higher GA/tumor frequency than MTAP+ UCB likely reflecting the frequent co-deletions of cyclin-dependent kinase inhibitor 2A/B. Of potential therapeutic targets, fibroblast growth factor receptor 3, and phosphatase and tensin homolog GA were more frequent in MTAP- UCB. In contrast, biomarkers of immunotherapy response, including higher frequencies of high tumor mutational burden and high programmed death-ligand 1 IHC staining, were observed in the MTAP+ UCB.

CONCLUSIONS

When compared with MTAP+ UCB, MTAP- UCB differs in genomic signatures including an increase in potentially targetable alterations but a lower frequency of immunotherapy drug biomarkers. Thus, the genomic landscape in MTAP- UCB may play a role in the design of clinical trials incorporating combination treatment strategies when targeting protein arginine methyltransferase 5 in MTAP- tumors.

Retrograde intrarenal surgery for lower pole stones utilizing stone displacement technique yields excellent results

Objective

To evaluate the long-term stone-free rate (SFR) of retrograde intra-renal surgery (RIRS) in the treatment of lower pole renal calculi using only basket relocation and identify independent predictors of stone-free status.

Methods

All consecutive patients undergoing RIRS lower pole renal calculi at a single high-volume tertiary center were analyzed retrospectively. Lower pole stones were relocated to the upper pole, where laser lithotripsy was performed. All patients were followed up in the clinic following the surgery and yearly thereafter. The stone-free status was assessed with a combination of an abdominal ultrasound and abdominal X-ray, or an abdominal non-contrast computed tomography if the stones were known to be radiolucent.

Results

A total of 480 consecutive patients who underwent RIRS for treatment of lower pole renal calculi, between January 2012 and December 2018, were analyzed from a prospectively maintained database of 3000 ureteroscopies. With a median follow-up time of 18.6 months, the mean SFR was 94.8%. The procedures were unsuccessful in 26 (5.4%) patients due to unreachable stones. The median stone size of the unreachable stones was 12 mm (range 10-30 mm). Multivariable logistic regression analysis revealed two predictors of SFR for lower pole stones: a small cumulative stone burden (odds ratio [OR]: 0.903, 95% confidence interval [CI]: 0.867-0.941, p<0.0001) and preoperative ureteral stent insertion (OR: 0.515, 95% CI: 0.318-0.835, p=0.007).

Conclusion

The long-term SFR of RIRS for the treatment of lower pole stones with basket displacement with appropriate patient selection is high.

Does antithrombotic use enable earlier diagnosis of bladder cancer? A brief institutional assessment

INTRODUCTION

Wallis et al (JAMA 2017) demonstrated use of antithrombotic medications (ATMs) is associated with increased prevalence of hematuria-related complications and subsequent bladder cancer diagnosis within 6 months. Stage of diagnosis was lacking in this highly publicized study. This study examined the association of ATM use on bladder cancer stage at the time of diagnosis.

MATERIALS AND METHODS

We completed a retrospective chart review of patients with a bladder cancer diagnosis at our institution. Patient demographics and bladder cancer work up information were assessed. Patients were stratified based on use of ATMs at time diagnosis. Descriptive statistics were completed to identify association between ATM use and stage of bladder cancer diagnosis, as stratified by non-muscle invasive bladder cancer (NMIBC) versus muscle invasive bladder cancer (MIBC).

RESULTS

A total of 1052 patient charts were reviewed. Eight hundred and forty-four were included and 208 excluded due to unavailability of diagnosis history. At diagnosis, 357 (42.3%) patients were taking ATMs. Patients on ATMs presented with NMIBC at similar rates as patients not taking ATMs (81.2% vs. 77.8%, p = 0.23). Subgroup analysis by ATM class similarly demonstrated no statistically significant differences in staging.

CONCLUSION

While Wallis et al established that patients on blood thinners who present with hematuria are more likely to be diagnosed with genitourinary pathology, this factor does not appear to enable an earlier diagnosis of bladder cancer. Future study may assess hematuria at presentation (gross, microscopic), type of blood thinners, and low versus high risk NMIBC presentation.

Role of Rucaparib in the Treatment of Prostate Cancer: Clinical Perspectives and Considerations

Prostate cancer is one of the most common types of cancer worldwide and has strong genetic associations. This is important for the development of therapeutics for the condition, as metastatic castrate-resistant prostate cancer (mCRPC) is resistant to standard androgen deprivation therapy (ADT) and has a relatively poor prognosis. We conducted a literature review on rucaparib, a poly(adenosine diphosphate-ribose) polymerase (PARP) inhibitor that is currently indicated for the treatment of patients with mCRPC who harbor mutations in BRCA1/2 (homologous recombination repair [HRR] genes) and who have already tried androgen receptor-axis-targeted therapies (ARAT) and a taxane chemotherapy. We describe rucaparib’s FDA approval, which was based on the results of the single-arm, open-label, Phase II TRITON2 clinical trial, which found an objective response rate (ORR) of 43.5%, a duration of response (DOR) of over six months in length and an acceptable safety profile. Rucaparib’s dosage and clinical considerations for use were also discussed. We also compared rucaparib’s use and safety profile with Olaparib, niraparib and talazoparib, three other PARP inhibitors tested for the treatment of mCRPC. Overall, initial results show that the safety profile of all four drugs in mCRPC was relatively similar, and further testing is currently indicated for all four. Differences in their metabolism, however, also warrant further research. The clinical validity of rucaparib will be tested by the follow-up TRITON3 clinical trial, which is comparing the effect of rucaparib compared to standard therapies for mCRPC harboring BRCA1/2 or ATM mutations. Other than TRITON3, other clinical trials are testing rucaparib’s ability against other cancers (prostate or otherwise) with HRR mutations, and also the efficacy of combination therapies involving rucaparib. Finally, more research is needed to elucidate rucaparib’s effect on HRR mutations other than BRCA1/2. Advancements in understanding the genetic landscape of mCRPC will also assist in understanding rucaparib’s full therapeutic potential.

Spontaneous stone expulsion in patients with history of urolithiasis

Objectives:

To examine differences in the presentation, management, and outcomes of patients admitted to the emergency department (ED) with ureteral stones, with prior history of urolithiasis compared to patients with a first stone event.

Patients and Methods:

Retrospective analysis of patients who visited the ED that were found to have a ureteral stone on CT. Patients were stratified into two groups: without history of urolithiasis (Group 1) and with history of urolithiasis (Group 2).

Results:

Between 2018 and 2020, 778 patients were admitted with ureteral stones. Patients in group 1 presented with a higher mean serum creatinine ( p = 0.02), larger mean stone size ( p < 0.0001), and a higher proportion of proximal ureteral stones ( p < 0.0001) than patients in group 2. The 30 day readmission rate was significantly higher in group 1 ( p = 0.02). Spontaneous stone expulsion was higher in group 2 ( p < 0.0001), whereas the need for endourological procedures was higher in group 1 ( p < 0.0001). On multivariable analysis serum creatinine (OR 0.264, 95% CI 0.091–0.769, p = 0.01) and stone size (OR 0.623, 95% CI 0.503–0.771, p < 0.0001) were associated with a lower spontaneous stone expulsion rate. History of prior endourological procedures (OR 0.225, OR 0.066–0.765, p = 0.01) was associated with a higher spontaneous stone expulsion rate.

Conclusions:

Our data suggests that patients who are first time stone formers present with larger and more proximal ureteral stones, with a lower likelihood of spontaneous stone expulsion and a subsequent need for surgical intervention. Previous stone surgery and not previous stone expulsion was found to be a predictor for spontaneous stone passage.

The association of sexual orientation with prostate, breast, and cervical cancer screening and diagnosis

PURPOSE

Data on heterogeneity in cancer screening and diagnosis rates among lesbians/gays and bisexuals (LGBs) is lacking. Recent studies showed that LGBs have decreased healthcare utilization compared to heterosexual counterparts. Few studies have examined how sexual orientation impacts cancer screening and prevalence. We, therefore, investigated the association between sexual orientation and prevalent sex-specific cancer including prostate (PCa), breast (BC), and cervical (CC) cancer.

METHODS

This was a cross-sectional survey-based US study, including men and women aged 18 + from the Health Information National Trends Survey (HINTS) database between 2017 and 2019. The primary endpoint was individual-reported prostate, breast, and cervical cancer screening and prevalence rates among heterosexual and LGB men and women. Multivariable logistic regression analyses assessed association of various covariates with undergoing screening and diagnosis of these cancers.

RESULTS

Overall, 4,441 and 6,333 heterosexual men and women, respectively, were compared to 225 and 213 LGB men and women, respectively. LGBs were younger and less likely to be screened for PCa, BC, and CC than heterosexuals. A higher proportion of heterosexual women than lesbian and bisexual women were screened for CC with pap smears (95.36% vs. 90.48% and 86.11%, p ≤ 0.001) and BC with mammograms (80.74% vs. 63.81% and 45.37%, p ≤ 0.001). Similarly, a higher proportion of heterosexual men than gay and bisexual men were screened for PCa with PSA blood tests (41.27% vs. 30.53% and 27.58%, p ≤ 0.001).

CONCLUSION

There were more heterosexuals than LGBs screened for CC, BC, and PCa. However, no association between sexual orientation and cancer diagnosis was found. Healthcare professionals should be encouraged to improve cancer screening among LGBs.

Prostate-specific Antigen Testing in Men with Disabilities: A Cross-sectional Analysis of the Health Information National Trends Survey

BACKGROUND

Patients with disabilities represent a unique minority population. The incidence of prostate-specific antigen (PSA) testing among this population is unknown.

OBJECTIVE

To compare PSA testing rates and associated predictors among men with and without reported disabilities in the USA.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study of the Health Information National Trends Survey (HINTS) for the years 2012, 2013, 2017 and 2019 was conducted in men with reported disabilities.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Baseline demographics of the entire cohort were stratified based on their reported disabilities (none, disabled, deaf, and blind). Each disability was compared separately and in combination with the cohort without disabilities. Multivariable logistic regression models determined clinically significant predictors of PSA testing in men with disabilities compared with those without.

RESULTS AND LIMITATIONS

Overall, 782 (15%) men with disabilities were compared with 4569 (85%) men without disabilities. The former cohort was older with a median (interquartile range) age of 65 (56-75) versus 57 (43-67) yr (p < 0.001). On multivariable analysis, men with any disability were less likely to undergo PSA testing (odds ratio 0.77, 95% confidence interval 0.62-0.96, p = 0.018). Variables associated with increased PSA testing included age, having a health care provider, health insurance, and living with a partner.

CONCLUSIONS

Inequalities in PSA testing exist among men with disabilities in the USA, especially among the deaf and blind, being less likely to undergo PSA testing. Further research is required to identify and deal with any obstacles in the implementation of equal PSA testing in this unique population.

PATIENT SUMMARY

In the USA, men with reported disabilities are less likely to undergo PSA testing than patients without reported disabilities.

Financial Toxicity and Its Association With Prostate and Colon Cancer Screening

BACKGROUND

The term "financial toxicity" or "hardship" is a patient-reported outcome that results from the material costs of cancer care, the psychological impacts of these costs, and the coping strategies that patients use to deal with the strain that includes delaying or forgoing care. However, little is known about the impact of financial toxicity on cancer screening. We examined the effects of financial toxicity on the use of screening tests for prostate and colon cancer. We hypothesized that greater financial hardship would show an association with decreased prevalence of cancer screening.

METHODS

This cross-sectional survey-based US study included men and women aged ≥50 years from the National Health Interview Survey database from January through December 2018. A financial hardship score (FHS) between 0 and 10 was formulated by summarizing the responses from 10 financial toxicity dichotomic questions (yes or no), with a higher score associated with greater financial hardship. Primary outcomes were self-reported occurrence of prostate-specific antigen (PSA) blood testing and colonoscopy for prostate and colon cancer screening, respectively.

RESULTS

Overall, 13,439 individual responses were collected. A total of 9,277 (69.03%) people had undergone colonoscopies, and 3,455 (70.94%) men had a PSA test. White, married, working men were more likely to undergo PSA testing and colonoscopy. Individuals who had not had a PSA test or colonoscopy had higher mean FHSs than those who underwent these tests (0.70 and 0.79 vs 0.47 and 0.61, respectively; P≤.001 for both). Multivariable logistic regression models demonstrated that a higher FHS was associated with a decreased odds ratio for having a PSA test (0.916; 95% CI, 0.867-0.967; P=.002) and colonoscopy (0.969; 95% CI, 0.941-0.998; P=.039).

CONCLUSIONS

Greater financial hardship is suggested to be associated with a decreased probability of having prostate and colon cancer screening. Healthcare professionals should be aware that financial toxicity can impact not only cancer treatment but also cancer screening.

Effect of age on presentation and outcome in renal colic

Objectives:

To examine the age-related differences in the presentation, management, and outcomes of patients admitted to the emergency department (ED) with ureteral stones.

Patients and methods:

A retrospective analysis of all patients who visited the ED at a single institution that were found to have a ureteral stone on CT. Clinical, laboratory, and imaging parameters were collected, including outcomes. Patients were subdivided into age groups: 18–30, 31–50, 51–70, and >70 years.

Results:

Between January 2018 and December 2020, 778 patients were admitted to the ED with a ureteral stone. About 78% (609) were males and 22% (169) were females. The mean ages were 49.4 (SD 14.4) and 51.6 (SD 15.7) in males and females, respectively ( p = 0.08). Patients in the 36–50 age group, had significantly higher visual analogue scale (VAS) scores ( p < 0.0001). Patients older than 70 years old presented with significantly higher serum creatinine levels ( p < 0.0001), C-reactive protein (CRP) ( p < 0.001) and leukocyte levels ( p = 0.002). These patients were also found to have significantly larger stones (mean size of 6.2 mm (SD 4.8) ( p < 0.0001)) and underwent percutaneous nephrolithotripsy (PCNL) in significantly higher numbers (56.3% vs 43.8%, ( p < 0.0001)). Less than half of the patients older than 50 years were given medical expulsive therapy (MET) with alpha-blockers, compared to more than 50% in the other age groups ( p = 0.002). Spontaneous stone expulsion was noted in 70.2% of the 18–35-year group, 62.4% of the 36–50-year-old group, 51.8% of the 51–70-year-old group, and 37% of the >70-year-old group ( p < 0.0001). The ED re-admission rates at 7 and 30 days were not significantly different among all age groups.

Conclusions:

Our data suggests that older patients presented with larger stones, elevated inflammatory markers and creatinine and were more likely to require surgical intervention. The spontaneous stone expulsion rate was inversely associated with age.

Landscape of fibroblast growth factor receptor (FGFR) genomic alterations (GA) in urothelial bladder cancer (UBC)

4568

Background: Urothelial bladder carcinomas (UBC) with genomic alterations (GA) in the Fibroblast Growth Factor Receptor ( FGFR) genes have been postulated to be less responsive to immune checkpoint inhibitors (ICI). Immune microenvironment of these tumors could be altered due to suppression of interferon signaling pathways. Here, we present comprehensive genomic profiling (CGP) of FGFR altered UBC to study the underlying immunogenomic mechanisms of response and resistance. Methods: 4,035 UBC underwent hybrid capture based CGP. Tumor mutational burden (TMB) was determined on up to 1.1 Mbp of sequenced DNA and microsatellite instability (MSI) was determined using 114 loci. Programmed death ligand (PD-L1) expression in tumor cells was assessed by IHC (Dako 22C3). Results: 894 (22%) of UBC featured FGFR GA ( FGFR1 3.7%; FGFR2 1.1%; FGFR3 17.4%). Gender and age distribution was similar in all groups. FGFR3 cases had lower GA/tumor and 14.7% GA were fusions. ERBB2 amplification was significantly higher in FGFR1/2 altered UBC compared with FGFR3 altered UBC. MTOR pathway GA were highest in FGFR3 altered UBC. FGFR3 altered UBC featured significantly higher frequencies of biomarkers predicting resistance to ICI including lower TMB, lower PD-L1 expression and higher frequencies of GA in MDM2. FGFR3 driven UBC also features significantly higher frequencies of CDKN2A/B loss and MTAP loss which have also recently been linked to IO drug resistance. Conclusions: UBC harboring FGFR GA have increased frequency of alterations that have been linked to ICI resistance. Further evaluation of FGFR-based biomarkers in UBC clinical trials focused on the assessment of the patient response to ICI appears warranted. [Table: see text]

The association of COVID-19 testing with cancer care disruption

e18558

Background: Research has shown that the COVID-19 pandemic has reduced access to cancer treatment and care for patients, especially for COVID-19 patients. Methods: We investigated the impact of COVID-19 testing on access to cancer care. A US based cross sectional study was conducted on 2,393 cancer patients using data from the 2020 National Health Interview Survey. Multivariable logistic regression was used to assess associations between COVID-19 testing and likelihood of receiving cancer treatment or other cancer care during the pandemic. Results: Patients who reported ever being tested for COVID were on average younger (66.9 vs 69.3, p<0.001). Patients with professional school education reported higher rates of being tested than lower education levels (40.0%, p=0.032). Tested patients reported higher rates of not receiving medical care due to COVID-19 (23.3% vs. 19.1%, p=0.026). On multivariable analysis, patients who reported ever being tested for COVID-19 were less likely to receive cancer treatment (OR 0.639, 95% CI 0.489-0.834, p=0.001) or receive any other cancer medical care (OR 0.657, 95% CI 0.523-0.825, p<0.001) (Table). Conclusions: These data suggest COVID testing itself is associated with increased likelihood of cancer care disruption. As the pandemic persists, awareness of cancer care disruption, even by testing alone, should be raised.[Table: see text]

What is the impact of ischemic heart disease on PSA testing?

e17014

Background: Prostate Specific Antigen (PSA) testing can improve early prostate cancer detection. However, numerous factors can influence patients’ willingness and ability to undergo PSA testing. Methods: We performed a cross-sectional study investigating the impact of various degrees of ischemic heart disease (IHD) on PSA testing. We assessed 3,822 male respondents aged 55-75 from the 2018 year of the National Health Interview Survey (NHIS). Men were stratified according to the degree of IHD (none, history of angina pectoris (AP), history of myocardial infarction (MI), or history of neither, but with a diagnosis of IHD). Multivariable logistic regression analysis was used to assess the relationship between IHD and being tested for PSA, adjusting for known cofounders. Results: Multivariable logistic regression demonstrated that males with a history of IHD (no MI or AP) were more likely to have ever been PSA tested than males without IHD (p = 0.012, OR = 1.630, 95% CI 1.115-2.383), as seen in Table. Additionally, older age (p < 0.001), having a partner (vs. no partner p < 0.001), homosexual sexual orientation (vs. heterosexual orientation p = 0.007), and a history of cancer (vs. no history p < 0.001) all increased likelihood of being PSA tested. In contrast, Asian race (vs. White, p = 0.001), and being a current smoker (vs. no smoking history, p < 0.001) decreased the likelihood. Interestingly, males with a history of a symptomatic IHD (MI or AP) were not shown to be more likely to undergo PSA testing. Conclusions: Our results suggest that males with non-symptomatic IHD are more likely to be PSA tested. Males with symptomatic IHD do not seem to undergo more PSA screening, perhaps due to lower suggested life expectancy. Awareness of discrepancies in PSA testing in men with IHD should be raised. Table - Multivariable logistic regression analyses demonstrating relationships with likelihood of being PSA tested.[Table: see text]

Comparison of long-term results following ureteroscopic stone fragmentation with removal versus stone dusting without removal

Purpose:

To compare long-term results following ureteroscopic stone fragmentation and removal versus stone dusting.

Methods:

We conducted a retrospective analysis of patients who underwent ureteroscopy for renal calculi at two high-volume tertiary centres between 2012 and 2013, therefore allowing long-term follow-up. The surgeons differed in their technique, some performing dusting for the most part and the others fragmentation. Inclusion criteria were stone free at the first follow-up and the sole use of laser lithotripsy is either by dusting or by fragmentation. Operative and post-operative data as well as re-treatment rates were compared between the groups. Stone-free rates and long-term stone recurrence rates were analysed by a single radiologist blinded to the treatment technique.

Results:

Between 2012 and 2013, 669 ureteroscopies were performed at both centres. The study group included 100 patients, which met the inclusion criteria, equally distributed between dusting and fragmentation. The cumulative stone diameter in patients treated with dusting was significantly larger (12.7 mm versus 17 mm, p = 0.006). Operative time was shorter in patients treated with dusting (56 minutes versus 47.2 minutes, p = 0.6). The mean follow-up was 58.9 (standard deviation (SD) 17.2) and 69.4 (SD 13.8) months for the fragmentation and dusting-treated patients, respectively( p = 0.06). The long-term recurrence rate in the fragmentation group was 22% compared to 38% in the dusting group ( p = 0 .08). Most of the patients in the dusting group required a repeat ureteroscopy during their follow-up (28% versus 6%, p = 0.003). A multivariable logistic regression analysis revealed that the fragmentation was not associated with a lower stone recurrence rate when compared to dusting (OR 0.6, 95% CI 0.199-1.810, p = 0.3).

Conclusions:

The recurrence rate of renal stones was not significantly influenced by the choice of surgical techniques. However, dusting was associated with a greater need for repeat ureteroscopy than fragmentation with removal.

Level of evidence:

Not applicable

Transrectal Ultrasound in Prostate Cancer: Current Utilization, Integration with mpMRI, HIFU and Other Emerging Applications

Transrectal ultrasound (TRUS) has been an invaluable tool in the assessment of prostate size, anatomy and aiding in prostate cancer (PCa) diagnosis for decades. Emerging techniques warrant an investigation into the efficacy of TRUS, how it compares to new techniques, and options to increase the accuracy of prostate cancer diagnosis. Currently, TRUS is used to guide both transrectal and transperineal biopsy approaches with similar cancer detection rates, but lower rates of infection have been reported with the transperineal approach, while lower rates of urinary retention are often reported with the transrectal approach. Multiparametric MRI has substantial benefits for prostate cancer diagnosis and triage such as lesion location, grading, and can be combined with TRUS to perform fusion biopsies targeting specific lesions. Micro-ultrasound generates higher resolution images that traditional ultrasound and has been shown effective at diagnosing PCa, giving it the potential to become a future standard of care. Finally, high-intensity focused ultrasound focal therapy administered via TRUS has been shown to offer safe and effective short-term oncological control for localized disease with low morbidity, and the precise nature makes it a viable option for salvage and repeat therapy.

Do weather parameters affect the incidence of renal colic in a predominantly warm country? A multicenter study

Purpose:

To determine whether there is any effect of weather parameters on the incidence of renal colic patients presenting to emergency rooms (ERs) during the hottest season in Israel.

Materials and Methods:

This retrospective multicenter study involved all ER admissions related to renal colic in nine centres throughout Israel between 2010 and 2017. The collected data included the date of ER visits, the patients’ age and sex, and the weather features of ambient temperature, wind velocity, noon heat index, and barometric pressure. Multivariable logistic regression analyses identified predictors of increased ER visits for renal colic.

Results:

There were 85,501 renal colic-related ER visits during the study period, involving 62,935 (74%) males and 22,566 (26%) females ( p < 0.005). The mean ± standard deviation (SD) age of the males and females was 50 ± 5.8 and 48 ± 19.6 years, respectively ( p = 0.1). Most of the ER arrivals were in the 31- to 50-year-old age group (37%, 31,508) ( p = 0.02). The maximal ambient temperature (odds ratio (OR) = 2.213, 95% confidence interval (CI) = 2.148–2.279, p < 0.0001), lower heat index (i.e. low humidity; OR = 0.880, 95% CI = 0.872–0.887, p < 0.0001) and increased wind velocity (OR = 1.165, 95% CI = 1.149–1.182, p < 0.0001) had a significant linear effect on ER visits for renal colic events.

Conclusion:

Conditions that increase sweat evaporation during the hottest months, including a decreased heat index and increased wind velocity, correlated with more ER visits for renal colic events, probably due to dehydration associated with elevated sweat evaporation.

Level of evidence:

Not applicable

The association of the use of anxiety and depression medications with PSA testing

56

Background: Mental illness is a growing issue in the USA. More individuals continue to be diagnosed with illnesses such as depression and anxiety and placed on necessary medications. Studies have shown that the psychological makeup of an individual greatly impacts their health behavior and usage of preventative measures. However, there is limited research on the effect of anxiety and depression on PSA testing. This study explores the associations between the use of anxiety and depression medications and PSA testing. Methods: We used data from the National Health Interview Survey during the year 2018, and assessed responses to the question “Have you ever had a PSA test?” and “What is the number of PSA tests you had in the last 5 years?”. Responses were stratified by whether men were taking medications for anxiety, depression, both or none. We performed multivariable logistic regression analysis to define adjusted odds ratios of undergoing PSA testing adjusting for relevant socio-economic and demographic parameters. Results: Among the 5,035 male participants, 89.4% did not take any medication, 2.9% reported they took anxiety medication, 2.1% took depression medication and 5.5% took both medications. There was a significantly higher rate of PSA testing in men who took medications for both anxiety and depression compared to men taking no medications (p=0.002). Furthermore, the average number of PSA tests in the last 5 years was highest in the group of men taking both medications ( p < 0.0001). Multivariable analysis showed that men who took medications for both depression and anxiety were more likely to undergo PSA testing in comparison to men, not on any of these medications (OR=1.755, p=0.001). The multivariable analysis also showed that age, living with a spouse, and prior cancer history were associated with an increased likelihood of PSA testing while being a minority, living in the south of the USA, and being a current smoker was associated with a lower likelihood of undergoing PSA testing. Conclusions: Taking both anxiety and depression medications in men may be associated with a higher likelihood of undergoing PSA testing. Despite obvious limitations of this analysis including its retrospective nature and recall bias, this association needs to be further explored, especially due to rising use of these medication in the current era of the COVID-19 pandemic.[Table: see text]

Financial toxicity and its effect on screening for prostate and colon cancer

21

Background: The term ‘financial toxicity’ or ‘hardship’ is used to describe the financial problems patients experience due to high out-of-pocket costs for their healthcare. Financial toxicity in the context of cancer treatment is an area of recent study due to the significant costs associated with these treatments, but little is known about the effect of financial toxicity on cancer prevention. We examined the effects of financial toxicity on the utilization of screening tests for prevalent cancers, including prostate and colon cancer, using a US nationally representative survey-based data source. We hypothesized that patients with more financial hardship would show an association with decreased prevalence of prostate and colon cancer screening. Methods: This cross-sectional survey-based US study included men and women aged 18+ from the National Health Interview Survey (NHIS) database from January – December 2018. A financial hardship score between 0 and 1 was formulated by summarizing the responses from ten financial toxicity questions including if in the past 12 months one was unable to afford prescription medication or healthcare; or if one had to skip or take less medicine to save money. A higher score was associated with a worse financial hardship score. The primary outcomes of the study were self-reported occurrence of PSA blood testing for prostate cancer screening, and occurrence of colonoscopy for colon cancer screening. Results: As shown in table, a higher financial hardship score was associated with a decreased odds ratio for having a PSA test of 0.916 (95% CI 0.867-0.967, p=0.002) and colonoscopy of 0.969 (95% CI 0.941-0.998, p=0.039). Conclusions: Worse financial hardship is associated with a decreased probability of having PSA or colonoscopy screening tests. Awareness of this specific toxicity needs to be raised, examining the association of financial toxicity and screening of prostate, colon, and other additional cancers. [Table: see text]

E-cigarette use and the risk of bladder and lung cancer

443

Background: Electronic cigarette smoking and similar novel smoking modalities have raised questions about their impact on various cancers compared with traditional forms of tobacco smoking. Tobacco smoking has been concretely proven to increase the risk of many cancers, including lung (LCa) and bladder (BCa) cancer. To date, there is little data on how e-cigarette smoking impacts the incidence of these cancers. We investigated whether any disparities exist in the prevalence of LCa and BCa between various smoking histories using a US nationally representative data source. Methods: This cross-sectional survey-based US study included men and women aged 18+ from the National Health Interview Survey (NHIS) database between 2016-2018. Primary endpoint was self-reported occurrence of LCa and BCa diagnosis. Multivariable logistic regression analyses assessed possible association of various covariates with diagnosis of these cancers. Results: Prevalence of BCa and LCa was higher in all smoking histories compared to never smokers. Patients with a history of e-cigarette smoking vs. no history of e-cigarette smoking were significantly younger at BCa diagnosis (56.87 [±9.86] vs. 65.00 [±12.60] years, p=0.001). Multivariable logistic regression models showed that a history of cigarette smoking and e-cigarette smoking individually was associated with increased ORs of 2.476 (p≤0.001) and 1.577 (p≤0.001) for BCa diagnosis, respectively, and 4.589 (p≤0.001) and 1.614 (p=0.007) for LCa diagnosis, respectively. Conclusions: Compared to never smokers, history of e-cigarette smoking was associated with increased risk of LCa and BCa development and earlier BCa diagnosis. Additional studies are needed to better define the public health effects of these novel and unregulated products.

Comparison of prostate specific antigen testing in men aged 55 to 69 with and without a history of cancer

230

Background: Prostate specific antigen (PSA) screening remains a controversial issue. However, most urological guidelines recommend PSA testing through a shared decision-making process with the patient. The rate of PSA screening in men with a history of cancer compared to men with no cancer history is not well known. We aimed to compare PSA testing in men aged 55-69 years with and without a history of cancer (excluding prostate cancer patients). Methods: Utilizing the National Health Interview Survey (NHIS) a retrospective cross-sectional study between the years 2015 and 2018 was carried out to analyze and compare PSA testing rates in men aged 55-69 years. Multivariable logistic regression model was implemented do demonstrate potential associations with PSA testing. Results: A total of 13,850 men aged 55-69 years included in the NHIS Survey were analyzed. 1519 (10.9%) men had a history of cancer (non-prostate). On multivariable analysis, men who were previously diagnosed with cancer had a higher rate of PSA testing compared to men with no history of cancer (OR: 1.88, 95% CI 1.39-2.54, p < 0.001). Other factors associated with an increased likelihood of undergoing PSA testing included: age, homosexual orientation, and married men. In contrast, current smokers, American Indians and Alaskan Natives and Asians were less likely to undergo PSA testing. Conclusions: Our data suggest that men aged 55-69 with a history of cancer are more likely to undergo PSA testing than men with no cancer history.[Table: see text]

The association of statin subgroups with lower urinary tract symptoms following a prostate biopsy

INTRODUCTION

This was a secondary analysis aiming to assess whether hydrophilic or hydrophobic statins have a differential effect on urinary retention (UR) and lower urinary tract symptoms (LUTS) in men following a prostate biopsy (PB), who were at risk for prostate cancer development.

METHODS

This was a population-based cohort study with data incorporated from the Institute for Clinical and Evaluative Sciences database to identify all Ontarian men aged 66 and above with a history of a single negative PB between 1994 and 2016, with no drug prescription history of any of several putative chemopreventative medications (statins, proton pump inhibitors, five-alpha-reductase inhibitors, and alpha-blockers). Multivariable Cox regression models with time-dependent covariates were used to assess the association of hydrophilic and hydrophobic statins with UR and LUTS within 30 days of a PB. All models were adjusted for other known putative chemopreventive medications, age, rurality, pharmacologically treated diabetes, comorbidity score, and study inclusion year.

RESULTS

Overall, 21 512 men were included, with a median followup time of 9.4 years (interquartile range [IQR] 5.4-13.4 years). Hydrophobic and hydrophilic statins were initiated by 30.7% and 19.6% of men, respectively, after the first negative PB. UR and LUTS were experienced by 2.2% and 10% of men, respectively. Cox models demonstrated hydrophilic statins were associated with a lower risk of UR (hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.38-0.83, p=0.0038) and LUTS (HR 0.86, 95% CI 0.76-0.98, p=0.022), while no such association was shown for hydrophobic statins.

CONCLUSIONS

Initiation of hydrophilic statins in men older than 66 appears to be inversely associated with the risk of UR and LUTS within 30 days of a PB.

Association of Race With Cancer-Related Financial Toxicity

PURPOSE

We investigated the association between race and FT among previous patients with cancer. Studies show that patients with cancer experience financial toxicity (FT) because of their cancer treatment.

METHODS

Data on individuals with a cancer history were collected in this cross-sectional study during 2012, 2014, and 2017, from the US Health Information National Trends Survey. This survey is conducted by mail with monetary compensation as an incentive. We specifically assessed responses to two questions: Has cancer hurt you financially? Have you been denied health insurance because of cancer? Multivariable logistic regression analyses were used to assess the associations between these questions and race.

RESULTS

Of 10,592 individuals participating, 1,328 men and women (12.5%) with a cancer history were assessed. Compared with Blacks, Whites were found to have a higher rate of insurance (95.4% v 90.0%), were more likely to receive cancer treatment (93.9% v 85%), and had a higher rate of surgical treatment than Blacks (77% v 60%), Hispanics (55%), and others (77%, 60%, 55%, and 74.2%, respectively, P < .001). On multivariable analysis, Blacks were more than five times as likely to be denied insurance (odds ratio, 5.003; 95% CI, 2.451 to 10.213; P < .001) and more than twice as likely to report being hurt financially because of cancer (odds ratio, 2.448; 95% CI, 1.520 to 3.941; P < .001) than Whites. Of all cancer groups analyzed (genitourinary, gynecologic, gastrointestinal, and breast), genitourinary malignancies were the only group in which the rate of reporting being hurt financially varied in a statistically significant manner (Whites 36.7%, Hispanics 62.5%, and Blacks 59.3%, P = .004).

CONCLUSION

Our data suggest that race is significantly associated with FT because of cancer. Awareness of racial inequality with regards to FT should be raised among health care workers.

The association of sexual orientation with prostate, breast, and cervical cancer screening and diagnosis

129

Background: Data on heterogeneity in cancer screening and diagnosis rates among lesbians/gays and bisexuals is lacking. Recent studies showed that lesbians/gays and bisexuals have decreased healthcare utilization compared to heterosexual counterparts and continue to experience discrimination in healthcare. Few studies have examined how sexual orientation impacts cancer screening and prevalence. We, therefore, investigated the association between sexual orientation and prevalent sex-specific cancer including prostate, breast, and cervical cancer. Methods: This was a cross-sectional survey-based US study, including men and women aged 18+ from the Health Information National Trends Survey (HINTS) database between 2017-2019. The primary endpoint was individual-reported prostate, breast, and cervical cancer screening and prevalence rates among heterosexual and LGB men and women. Multivariable logistic regression analyses assessed association of various covariates with undergoing screening and diagnosis of these cancers. Results: Overall, 4,441 and 6,333 heterosexual men and women, respectively, were compared to 225 and 213 lesbian/gay and bisexual men and women, respectively. Lesbians/gays and bisexuals were younger and less likely to be screened for prostate, breast, and cervical cancer than heterosexuals. A higher proportion of heterosexual women than lesbian and bisexual women were screened for cervical cancer with pap smears (95.36% vs. 90.48% and 86.11%, p = < 0.001) and breast cancer with mammograms (80.74% vs. 63.81% and 45.37%, p = < 0.001). Similarly, a higher proportion of heterosexual men than gay and bisexual men were screened for prostate cancer with PSA blood tests (41.27% vs. 30.53% and 27.58%, p = < 0.001). Conclusions: Lesbians/gays and bisexuals in the US may be less likely to undergo screening of sex-specific prevalent malignancies, including prostate, breast, and cervical cancer. Healthcare professionals should be encouraged to improve cancer screening among lesbians/gays and bisexuals.

Clinically Advanced Pheochromocytomas and Paragangliomas: A Comprehensive Genomic Profiling Study

Simple Summary

Clinically advanced pheochromocytomas and paragangliomas are a rare form of endocrine malignancy which can occur in familial and sporadic clinical settings and feature a variety of genomic alterations. Comprehensive genomic profiling (CGP) was performed to characterize the genomic alterations (GA) in clinically advanced disease to enable the search for potential therapy targets. Although the GA/tumor is relatively low for clinically advanced disease, CGP can reveal important potential targets for therapy in the metastatic setting including RET, NF1 and FGFR1. Based on this data, further study of CGP as a method of developing precision therapies for clinically advanced disease appears warranted.

Abstract

Patients with clinically advanced paragangliomas (CA-Para) and pheochromocytomas (CA-Pheo) have limited surgical or systemic treatments. We used comprehensive genomic profiling (CGP) to compare genomic alterations (GA) in CA-Para and CA-Pheo to identify potential therapeutic targets. Eighty-three CA-Para and 45 CA-Pheo underwent hybrid-capture-based CGP using a targeted panel of 324 genes. Tumor mutational burden (TMB) and microsatellite instability (MSI) were determined. The GA/tumor frequencies were low for both tumor types (1.9 GA/tumor for CA-Para, 2.3 GA/tumor for CA-Pheo). The most frequent potentially targetable GA in CA-Para were in FGFR1 (7%, primarily amplifications), NF1, PTEN, NF2, and CDK4 (all 2%) and for CA-Pheo in RET (9%, primarily fusions), NF1 (11%) and FGFR1 (7%). Germline mutations in known cancer predisposition genes were predicted in 13 (30%) of CA-Pheo and 38 (45%) of CA-Para cases, predominantly involving SDHA/B genes. Both CA-Para and CA-Para had low median TMB, low PD-L1 expression levels and none had MSI high status. While similar GA frequency is seen in both CA-Para and CA-Para, germline GA were seen more frequently in CA-Para. Low PD-L1 expression levels and no MSI high status argue against strong potential for novel immune checkpoint inhibitors. However, several important potential therapeutic targets in both CA-Para and CA-Para are identified using CGP.

The association of sexual orientation with cancer screening and diagnosis

6506

Background: Data on heterogeneity in cancer screening and diagnosis rates among sexual minorities (SMs) is lacking. Recent studies have shown SMs are more likely to engage in risky health behavior and have decreased healthcare utilization compared to heterosexual counterparts. However, few studies have examined how sexual orientation (SO) impacts cancer screening and prevalence. We therefore investigated whether SO affects prevalent gender-specific cancer screening and prevalence, including prostate (PCa), breast (BC), and cervical cancer (CC). Methods: This was a cross-sectional survey-based US study, including men and women aged 18+ from the Health Information National Trends Survey (HINTS) database (part of the National Cancer Institute’s division of cancer control and population sciences) between 2017-2019. The primary endpoint was individual-reported PCa, BC, and CC screening and prevalence rates among heterosexual and SM men and women. Multivariable logistic regression analyses assessed association of various covariates with undergoing screening and diagnosis of these cancers. Results: Overall, 4,441 (95.18%) men and 6,333 (96.75%) women reported a SO of heterosexual whereas 167 (3.6%) and 58 (1.2%) men and 105 (1.6%) and 108 (1.6%) women reported a SO of gay and bisexual, respectively. Mean age was higher in the heterosexual group compared to the gay and bisexual groups in both men (57.7 [±16.0] vs. 52.4 [±14.5] and 51.9 [±18.0] years, p = < 0.001) and women (56.2 [±16.7] vs. 49.0 [±17.1] and 40.0 [±14.8] years, p = < 0.001). Homosexuals and bisexuals were less likely to be screened for PCa (30.53% and 27.58% vs 41.27%, p = < 0.001), BC (63.81% and 45.37% vs 80.74%, p = < 0.001), and CC (90.48% and 86.11% vs 95.36%, p = < 0.001) than their heterosexual counterparts. While rates of PCa and BC diagnoses were similar across SO, more homosexual and bisexual women were diagnosed with CC compared to their heterosexual counterparts (4.76% and 3.70% vs 1.85%, p = 0.039). Multivariable logistic regression models showed that SMs were less likely to be screened for cancer with ORs of 0.61 (95% CI 0.39-0.95, p = 0.030) for PCa, 0.52 (95% CI 0.30-0.92, p = 0.025) for BC, and 0.21 (95% CI 0.09-0.46, p = < 0.001) for CC. Although multivariable models did not show that SMs were more likely to be diagnosed with PC, BC, or CC, SMs were more likely to be diagnosed with any cancer with ORs of 1.64 (95% CI 1.06-2.54, p = 0.026) in women only and 1.50 (95% CI 1.11-2.03, p = 0.009) in men and women combined. Conclusions: These data suggest that in addition to other established and known specific socio-economic risk factors, SMs may be less likely to undergo screening of prevalent malignancies such as PCa, BC, and CC. This provides more evidence of ongoing healthcare inequality, urging our healthcare system to invest more in cancer screening of this vulnerable population.

The influence of race on financial toxicity among cancer patients

1525

Background: Studies show that cancer patients and survivors are likely to endure financial toxicity long after being diagnosed. Methods: To examine the influence of race on financial toxicity among individuals with a history of cancer, a US based cross sectional study was conducted using data on 1,328 cancer patients collected from the Health Information National Trends Survey. Multivariable logistic regression analyses were used to analyze the relationship between race and financial toxicity, adjusting for known confounders. Results: Blacks, Hispanics and other races were shown to have a lower rate of insurance compared to Whites. Whites were also more likely to receive cancer treatment than other races (6.1% received no treatment vs 15.0% of Blacks, 17.8% of Hispanics, and 9.7% of other races, p<0.001). Considerably more Whites underwent surgical treatment of their cancer (77%) vs. 60% of Blacks, 55% of Hispanics and 74.2% of other races, p<0.001. Blacks were found to be over 5 times more likely to be denied insurance (OR 5.003, 95% CI 2.451-10.213, p<0.001) and more than twice as likely to be hurt financially than Whites (OR 2.448, 95% CI 1.520-3.941, p<0.001). Other racial minorities were also more than twice as likely to be hurt financially than Whites (OR 2.421, 95% CI 1.248-4.698, p=0.009) (Table). Conclusions: These data suggest that race is significantly associated with increased rates of being hurt financially and being denied insurance due to cancer. Awareness of race inequality should be raised so that equal cancer treatment can be provided, irrespective of race, gender or socioeconomic status.[Table: see text]

Prostate-specific antigen testing in the disabled population: A cross-sectional analysis of the Health Information National Trends Survey (HINTS)

e17000

Background: Disabled patients are a unique minority population that may have lower literacy levels and difficulty communicating with physicians. Furthermore, their knowledge for cancer prevention recommendations is unknown. Herein, we aim to compare prostate-specific antigen (PSA) testing rates and associated predictors among disabled men and non-disabled men in the USA. Methods: We performed a cross-sectional study utilizing the Health Information National Trends Survey (HINTS) to analyze factors predicting PSA testing rates in men with disabilities (disabled, deaf, blind). Multivariable logistic regression models were used to determine clinically significant predictors of PSA testing in men with disabilities compared to that of the healthy cohort. Results: A total of 782 (14.6%) disabled men were compared to 4,569 (85.4%) non-disabled men. Disabled men were older with a mean age of 65.0 ± 14.2 vs. 55.0 ± 15.9 years (p < 0.001). On multivariable analysis, after adjusting for all available confounders including race, age, geographical region, survey year, marital status, health insurance, healthcare provider, amongst others, men with any disability were less likely to undergo PSA screening (OR 0.772, 95% CI 0.623-0.956, p = 0.018). Variables associated with increased PSA screening rates included age, having a healthcare provider or health insurance, and living with a partner. Although prostate cancer detection rates were shown to be higher among disabled men, this did not reach statistical significance. Conclusions: Our data suggests that significant inequalities in PSA screening exist among men with disabilities in the USA, with disabled men, especially the deaf and the blind, being less likely to be offered PSA screening. There is a clear need to implement strategies to reduce existing gaps in the care of disabled men and strive to reach equality in PSA screening in this unique population.

The association between sexual orientation and screening of prevalent gender-specific cancers

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Background: Data on heterogeneity in cancer screening and diagnosis rates among sexual minorities (SMs) is lacking. Recent studies have shown SMs are more likely to engage in risky health behavior and have decreased healthcare utilization. However, few studies have examined how sexual orientation impacts cancer screening and prevalence. We therefore investigated whether sexual orientation affects prevalent gender-specific cancer including prostate (PCa), breast (BC), and cervical cancer (CC). Methods: This was a cross-sectional survey-based US study, including men and women aged 18+ from the Health Information National Trends Survey (HINTS) database (part of the National Cancer Institute’s division of cancer control and population sciences) between 2017-2019. The primary endpoint was individual-reported PCa, BC, and CC screening and prevalence rates among heterosexuals and homosexuals/bisexuals. Multivariable logistic regression analyses assessed association of various covariates with undergoing screening and diagnosis of these cancers. Results: Overall, 4,441 and 6,333 heterosexual men and women, respectively, were compared to 225 and 213 homosexual/bisexual men and women, respectively. Homosexuals/bisexuals were younger and less likely to be screened for PCa (34.7% vs 41.3%, p=0.013), BC (54.5% vs 80.7%, p=<0.001), and CC (88.3% vs 95.4%, p=<0.001). While rates of PCa and BC diagnosis were similar, more than twice as many homosexual/bisexual women were diagnosed with CC (4.2% vs 1.9%, p=0.023). Multivariable logistic regression models (Table) showed homosexuals/bisexuals were less likely to be screened for cancer with ORs of 0.61 (95% CI 0.39-0.95) for PCa, 0.52 (95% CI 0.30-0.92) for BC, and 0.21 (95% CI 0.09-0.46) for CC. Homosexuals/bisexuals were more likely to be diagnosed with any cancer with ORs of 1.64 (95% CI 1.06-2.54) in women only and 1.50 (95% CI 1.11-2.03) in men and women combined. Conclusions: Homosexuals/bisexuals in the US may be less likely to undergo screening of gender-specific prevalent malignancies, including PCa, BC, and CC. The implementation of cancer screening among SMs should be improved. [Table: see text]

Upgrading on radical prostatectomy specimens of very low- and low-risk prostate cancer patients on active surveillance: A population-level analysis

INTRODUCTION

A proportion of prostate cancer (PCa) patients initially managed with active surveillance (AS) are upgraded to a higher Gleason score (GS) at the time of radical prostatectomy (RP). Our objective was to determine predictors of upgrading on RP specimens using a national database.

METHODS

The Surveillance, Epidemiology, and End Results Prostate with Watchful Waiting database was used to identify AS patients diagnosed with very low- or low-risk PCa who underwent delayed RP between 2010 and 2015. The primary outcome was upgrading to GS 7 disease or worse. Logistic regression analyses were used to evaluate demographic and oncological predictors of upgrading on final specimen.

RESULTS

A total of 3775 men underwent RP after a period of AS, 3541 (93.8%) of whom were cT2a; 792 (21.0%) patients were upgraded on RP specimen, with 85.4%, 10.6%, and 3.4% upgraded to GS 7(3+4), 7(4+3), and 8 diseases, respectively. On multivariable analysis, higher prostate-specific antigen (PSA) at diagnosis (5-10 vs. 0-2 ng/ml, odd ratio [OR] 2.59, p<0.001) and percent core involvement (80-100% vs. 0-20%, OR 2.52, p=0.003) were significant predictors of upgrading on final RP specimen, whereas higher socioeconomic status predicted lower odds of upgrading (highest vs. lowest quartile OR 0.75, p=0.013).

CONCLUSIONS

Higher baseline PSA and percent positive cores involvement are associated with significantly increased risk of upgrading on RP after AS, whereas higher socioeconomic status predicts lower odds of such events. These results may help identify patients at increased risk of adverse pathology on final specimen who may benefit from earlier definitive treatment.

Is there an association between a history of military service and cancer diagnosis? Results from a US national-level study of self-reported outcomes

PURPOSE

To examine cancer prevalence in men with and without military service history, using national-level self-reported outcomes.

METHODS

A cross-sectional survey-based US study, including men aged 18 and above from the Health Information National Trends Survey database between 2011 and 2014. The primary endpoint was self-reported cancer prevalence. Multivariable logistic regression analyses assessed the association of various covariates with the prevalence of cancer.

RESULTS

A total of 4,527 men were analyzed, with 1,352 (29.9%) reporting a history of military service. Compared to men with no military service history, men with a military service history were older (median of 65 [IQR 56, 74] vs. 53 [IQR 41, 62] years, p < 0.0001), more commonly Caucasian (71.4% vs. 61.4%, p < 0.0001), born in the US (95.6% vs. 79.5%, p < 0.0001), attained higher education level and annual household income (p < 0.0001), and consisted of more smokers(58.3% vs. 44.5%, p < 0.0001). The age-adjusted comparison demonstrated a higher cancer prevalence in men with military service history (20.5% vs. 7.6%, p < 0.0001). Specifically, genitourinary, dermatological, gastrointestinal, and hematological cancers were generally more prevalent. Adjusting for all available confounders, multivariable models showed that military service history was associated with 1.56 (95% CI 1.20-2.03), and 1.57 (95% CI 1.07-2.31) increased odds of having any cancer, and specifically genitourinary cancer, respectively.

CONCLUSIONS

Further research is needed to ascertain whether the association between military service and increased cancer diagnosis results from better screening programs or increased exposure to risk factors during military service.

Can post-treatment free PSA ratio be used to predict adverse outcomes in recurrent prostate cancer?

OBJECTIVES

To assess whether free PSA ratio (FPSAR) at biochemical recurrence (BCR) can predict metastasis, castrate-resistant prostate cancer (CRPC), and cancer-specific survival (CSS), following therapy for localised disease.

PATIENTS AND METHODS

A single-centre retrospective cohort study (NCT03927287) including a discovery cohort composed of patients with an FPSAR after radical prostatectomy (RP) or radiotherapy (RT) between 2000 and 2017. For validation, an independent Biobank cohort of patients with BCR after RP was tested. Using a defined FPSAR cut-off, the metastasis-free-survival (MFS), CRPC-free survival, and CSS were compared. Multivariable Cox models determined the association between post-treatment FPSAR, metastases, and CRPC.

RESULTS

Overall, 822 patients (305 RP- and 363 RT-treated patients and 154 Biobank patients) were analysed. In the RP cohort, a total of 272/305 (89.1%) and 33/305 (10.9%) had a FPSAR test incidentally and reflexively, respectively. In the RT cohort, 155/363 (42.7%) and 208/263 (57.3%) had a FPSAR test incidentally and reflexively, respectively. However, in the prospective Biobank RP cohort, FPSAR testing was done on all samples of patients diagnosed with BCR. A FPSAR cut-off of 0.10 was determined using receiver operating characteristic analyses in both the RP and RT cohorts. A FPSAR of <0.10 resulted in longer median MFS (14.8 vs 9.3 years and 14.8 vs 13 years, respectively), and longer median CRPC-free survival (median not reached vs 9.9 years and 20.7 vs 13.8 years, respectively). Multivariable analyses showed that a FPSAR of ≥0.10 was associated with increased metastasis in the RP cohort (hazard ratio [HR] 1.915, 95% confidence interval [CI] 1.241-2.955) and RT cohort (HR 1.754, 95% CI 1.112-2.769), and increased CRPC in the RP cohort (HR 2.470, 95% CI 1.493-4.088). Findings were validated in the Biobank cohort.

CONCLUSIONS

A post-treatment FPSAR of ≥0.10 is associated with more aggressive disease, suggesting a potentially novel role for this biomarker.

The suggested chemopreventive association of metformin with prostate cancer in diabetic patients

PURPOSE

Metformin, an insulin sensitizer, is the most common first-line antidiabetic therapy. There is increasing evidence suggesting metformin can prevent the emergence of prostate cancer (CaP). We aimed to analyze the chemopreventive role of metformin, in conjunction with other putative chemopreventive medications (statins, proton-pump-inhibitors, alpha-blockers, 5-alpha-reductase inhibitors, diabetic medications) in a population-based cohort study.

METHODS

Data were incorporated from the Institute for Clinical and Evaluative Sciences to identify all diabetic men aged 66 and above with prior history of a negative prostate biopsy (PB) between 1994 and 2016, who were not on any of the medications prior to study inclusion. Multivariable Cox regression models with time-dependent covariates were used to assess the association of metformin to CaP diagnosis, subsequent PB, and use of androgen deprivation therapy (ADT). All models were adjusted for age, rurality, comorbidity, and year of study inclusion.

RESULTS

Overall, 2,332 diabetic men were included, with a median follow-up time of 9.4 years (interquartile range 5.4-13.4 years). A total of 2,036 patients (87.3%) received metformin. Compared to non-metformin users, metformin use was associated with decreased CaP diagnosis rate (HR 0.69, 95%CI 0.54-0.88, P = 0.003), lower hazard of undergoing an additional PB (HR 0.64, 95%CI 0.44-0.95, P = 0.03), and receiving ADT (HR 0.72, 95%CI 0.54-0.96, P = 0.003).

CONCLUSION

Men receiving metformin were less likely to have suspected or diagnosed CaP, and in those with CaP, the use of ADT was less common. Ongoing prospective randomized studies will determine if these findings correspond to the suggested associations of metformin in the emergence and/or progression of CaP.

Long-term Surveillance of Patients with Complete Response Following Chemotherapy for Metastatic Nonseminomatous Germ Cell Tumor

BACKGROUND

There is controversy regarding the management of patients with normal markers and residual masses (≤1 cm) after chemotherapy for nonseminomatous germ cell tumors (NSGCTs).

OBJECTIVE

To determine long-term outcomes of a surveillance strategy in such patients.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of our multidisciplinary testicular cancer database was performed. All patients who underwent primary chemotherapy for metastatic NSGCTs were identified between 1981 and 2016. A complete response (CR) was defined as normalization of serum tumor markers and a ≤1 cm residual mass in the largest axial dimension following chemotherapy. All such patients were surveilled.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Outcome variables of interest were time to death, time to cancer-specific survival, and time to relapse. Overall survival and relapse-free survival were calculated using the Kaplan-Meier method, and the cumulative incidence of cause-specific survival rates was calculated using competing risk analysis. The impact of risk group and chemotherapy regimen on relapse-free survival was assessed using log-rank test.

RESULTS AND LIMITATIONS

During the study period, 1429 metastatic germ cell tumor patients were treated with primary chemotherapy. CR was achieved in 191 (18.5%) NSGCT patients. The median age at diagnosis was 27.4 yr, with a median follow-up of 81.1 mo. The majority had American Joint Committee on Cancer stage II at diagnosis (I: 23.8%; II: 49.2%; III: 27%) and International Germ Cell Cancer Collaborative Group good-risk disease (good: 78%; intermediate: 17.8%; poor: 4.2%). Of the 191 patients with a CR, 175 (91.6%) never relapsed and remain disease free. Sixteen (8.4%) patients relapsed after a median of 11.3 mo (range 1-332 mo), with over half (nine patients; 4.7%) relapsing in the retroperitoneum only and salvaged successfully with postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) alone. Of these nine patients, only two (1%) had viable disease in the PC-RPLND specimen. The remaining seven patients had relapses outside the retroperitoneum and received salvage chemotherapy ± postchemotherapy resection. Overall, nine (4.7%) patients have died, but only four (2.1%) from testis cancer.

CONCLUSIONS

Our data, the largest series to date, confirm that surveillance is safe and effective for men who achieve a CR following chemotherapy for metastatic NSGCTs.

PATIENT SUMMARY

Surveillance is a safe strategy for patients who achieve a complete response following chemotherapy for metastatic testis cancer.