An external validation of the nocera nomogram: Predicting non-organ confined stage of ≥pT3 in cT1 clear cell renal cell carcinoma

Background

Only one previously published study by Nocera et al. addressed the risk of upstaging to ≥pT3 in cT1 clear cell renal cell carcinoma (ccRCC) by using characteristics of the R.E.N.A.L and PADUA score (age, tumor size, rim location, exophytic rate, polar involvement) developing an accurate nomogram. However, this nomogram has never been externally validated yet.

Material and methods

The study cohort consisted of 288 patients with cT1a-b ccRCC, diagnosed between 2008-2021 at the University Hospital Frankfurt, Germany. Analyses addressed clinical, tumor and radiographic characteristics. The external validation of the nomogram relied on accuracy calculations derived from the area under the curve of the receiver operator characteristic analysis.

Results

Overall, 11.8% (n=34) patients harbored ≥pT3 ccRCC. Median radiographic tumor size (3.6 vs. 5.3cm), R.E.N.A.L. (8 vs. 9 points) and PADUA score (9 vs. 11 points), as well as proportions of renal sinus involvement (82.4% vs. 51.6%), renal hilus involvement (44.1 vs. 13.0%), and medial rim location significantly differed between the pT1-2 and ≥pT3 group (all p ≤ 0.01). In subgroup analyses of small renal mass ccRCC patients (<4cm, cT1a), only 3.8% (n=6) patients had ≥pT3 pathology. Upstaged patients were significantly older and more frequently had endophytic tumor than pT1-2 counterparts (p<0.05). The external validation of the Nocera nomogram showed a good accuracy of 76.6%. Using the suggested cut-off of 21%, 26.5% of patients exhibited ≥pT3 ccRCC. Conversely, within patients below cut-off, 5.9% patients exhibited ≥pT3 ccRCC.

Conclusion

We reported the first external validation of the nomogram addressing the risk of ≥pT3 in cT1 ccRCC patients, demonstrating a good accuracy, with a low false-negative rate. Therefore, the nomogram can accurately be used for patients’ counselling and treatment decision making.

The Impact of Preoperative Double-J Stent on Perioperative Complications, Recurrence, and Quality of Life in Adult Patients Undergoing Pyeloplasty

PURPOSE

This study aimed to evaluate the impact of preoperative double-J stent (DJ) in pyeloplasty patients on perioperative complications, recurrence, and quality of life (QoL).

METHODS

Pyeloplasties due to ureteropelvic junction obstructions between January 2010 and December 2020 were consecutively identified. A standardized follow-up questionnaire was used. Tabulation was made according to preoperative DJ versus no DJ. Subgroup analyses addressed primary robotic pyeloplasties.

RESULTS

Of 95 pyeloplasty patients, 62% received a preoperative DJ. Patients with preoperative DJ exhibited higher rates of Clavien-Dindo (CD) 2 (22 vs. 11%) complications, but not of CD3 (8.5 vs. 8.3%, p = 0.5). After a median follow-up of 61 months, 9 patients exhibited a recurrence, of whom 7 had a preoperative DJ. In QoL assessment, comparable findings were made between patients with and without preoperative DJ. In robotic pyeloplasty patients (n = 73), patients with preoperative DJ (58%, n = 42) experienced higher CD3 complication rates, compared to patients without preoperative DJ (12 vs. 6.5%). Moreover, higher rates of recurrences were observed in preoperative DJ patients (12 vs. 3.2%).

CONCLUSION

In a contemporary pyeloplasty cohort, the midterm success rate was good with 91%. Our findings suggest that preoperative DJ is associated with higher recurrence rates. However, QoL did not differ between patients with and without preoperative DJ.

Where Is the Value in Ambulatory Versus Inpatient Surgery?

OBJECTIVE

The aim of this study was to estimate the effect of index surgical care setting on perioperative costs and readmission rates across 4 common elective general surgery procedures.

SUMMARY BACKGROUND DATA

Facility fees seem to be a driving force behind rising US healthcare costs, and inpatient-based fees are significantly higher than those associated with ambulatory services. Little is known about factors influencing where patients undergo elective surgery.

METHODS

All-payer claims data from the 2014 New York and Florida Healthcare Cost and Utilization Project were used to identify 73,724 individuals undergoing an index hernia repair, primary total or partial thyroidectomy, laparoscopic cholecystectomy, or laparoscopic appendectomy in either the inpatient or ambulatory care setting. Inverse probability of treatment weighting-adjusted gamma generalized linear and logistic regression was employed to compare costs and 30-day readmission between inpatient and ambulatory-based surgery, respectively.

RESULTS

Approximately 87% of index surgical cases were performed in the ambulatory setting. Adjusted mean index surgical costs were significantly lower among ambulatory versus inpatient cases for all 4 procedures (P < 0.001 for all). Adjusted odds of experiencing a 30-day readmission after thyroidectomy [odds ratio (OR) 0.70, 95% confidence interval (CI), 0.53-0.93; P = 0.03], hernia repair (OR 0.28, 95% CI, 0.20-0.40; P < 0.001), and laparoscopic cholecystectomy (OR 0.37, 95% CI, 0.32-0.43; P < 0.001) were lower in the ambulatory versus inpatient setting. Readmission rates among ambulatory versus inpatient-based laparoscopic appendectomy were comparable (OR 0.63, 95% CI, 0.31-1.26; P = 0.19).

CONCLUSIONS

Ambulatory surgery offers significant costs savings and generally superior 30-day outcomes relative to inpatient-based care for appropriately selected patients across 4 common elective general surgery procedures.

Radical Cystectomy vs. Multimodality Treatment in T2N0M0 Bladder Cancer: A Population-based, Age-matched Analysis

BACKGROUND

Controversy still exists regarding efficacy of multimodality treatment (MMT) vs. radical cystectomy (RC) for urothelial carcinoma of the urinary bladder (UCUB).

METHODS

Within the SEER database (2004-2016), we retrospectively identified patients with stage T2N0M0 UCUB. Competing risks regression (CRR) tested cancer-specific mortality (CSM) and adjusted for other-cause mortality after MMT vs. RC. Exact matching for age was applied. Subgroup analyses focused on differences in chemotherapy or lymph node dissection rates. In sensitivity analyses, we accounted for 40% understaging rate in patients who underwent MMT.

RESULTS

Of 9862 patients with T₂N₀M₀ UCUB, 2675 (27.1%) underwent MMT vs. 5751 (58.3%) RC vs. 1436 (14.6%) radiotherapy (RT) without chemotherapy. MMT rate increased (annually +3.0%, P < .01) and MMT patient age was significantly higher (median 77 years) than RC patient age (68 years). In exact age-matched analyses, 10-year CSM rates were 44.3% vs. 25.9% for MMT vs. RC (multivariate hazard ratio [HR] 0.48); 44.1% vs. 22.8% for MMT vs. RC with chemotherapy (HR 0.43); 40.5% vs. 31.1% for MMT vs. RC without lymph node dissection (HR 0.66), and 55.6% vs. 27.3% for RT without chemotherapy vs. RC (HR 0.37, all P < .001). Sensitivity analyses that addressed understaging of patients who underwent MMT resulted in virtually the same CSM rates.

CONCLUSION

In patents with T₂N₀M₀, MMT or even more so RT alone may be associated with higher CSM than RC, even in exact age-matched multivariate CRR analyses, which adjust for other-cause mortality. In consequence, patients with T2 UCUB should be informed of this possible CSM disadvantage outside of highly specialized centers.

Is Standardization Transferable? Initial Experience of Urethral Surgery at the University Hospital Frankfurt

Background: Since January 2018 performance of urethroplasties is done on regular basis at the University Hospital Frankfurt (UKF). We aimed to implement and transfer an institutional standardized perioperative algorithm for urethral surgery (established at the University Hospital Hamburg-Eppendorf—UKE) using a validated Urethral Stricture Surgery Patient-Reported Outcome Measure (USS-PROM) in patients undergoing urethroplasty at UKF.

Materials and Methods: We retrospectively analyzed all patients who underwent urethroplasty for urethral stricture disease between January 2018 and January 2020 at UKF. All patients were offered to revisit for clinical follow-up (FU) and completion of USS-PROM. Primary end point was stricture recurrence-free survival (RFS). Secondary endpoints were functional outcomes, quality of life (QoL), and patient satisfaction.

Results: In total, 50 patients underwent urethroplasty and 74 and 24% had a history of previous urethrotomy or urethroplasty, respectively. A buccal mucosal graft urethroplasty was performed in 86% (n = 43). After patient's exclusion due to lost of FU, FU <3 months, and/or a pending second stage procedure, 40 patients were eligible for final analysis. At median FU of 10 months (interquartile-range 5.0–18.0), RFS was 83%. After successful voiding trial, the postoperative median Qmax significantly improved (24.0 vs. 7.0 mL/s; p < 0.01). Conversely, median residual urine decreased significantly (78 vs. 10 mL; p < 0.01). Overall, 95% of patients stated that QoL improved and 90% were satisfied by the surgical outcome.

Conclusions: We demonstrated a successful implementation and transfer of an institutional standardized perioperative algorithm for urethral surgery from one location (UKE) to another (UKF). In our short-term FU, urethroplasty showed excellent RFS, low complication rates, good functional results, improvement of QoL and high patient satisfaction. PROMs allow an objective comparison between different centers.

Recovery from minimally invasive vs. open surgery in kidney cancer patients: Opioid use and workplace absenteeism

Purpose

Does surgical approach (minimally invasive vs. open) and type (radical vs. partial nephrectomy) affects opioid use and workplace absenteeism.

Materials and Methods

Retrospective multivariable regression analysis of 2,646 opioid-naïve patients between 18 and 64 undergoing radical or partial nephrectomy via either a minimally invasive vs. open approach for kidney cancer in the United States between 2012 and 2017 drawn from the IBM Watson Health Database was performed. Outcomes included: (1) opioid use in opioid-naïve patients as measured by opioid prescriptions in the post-operative setting at early, intermediate and prolonged time periods and (2) workplace absenteeism after surgery.

Results

Patients undergoing minimally invasive surgery had a lower odds of opioid use in the early and intermediate post-operative periods (early: odds ratio [OR], 0.77; 95% confidence interval [CI], 0.62–0.97; p=0.02, intermediate: OR, 0.60; 95% CI, 0.48–0.75; p<0.01), but not in the prolonged setting (prolonged: OR, 1.00; 95% CI, 0.75–1.34; p=0.98) and had earlier return to work (minimally invasive vs. open: −10.53 days; 95% CI, −17.79 to −3.26; p<0.01). Controlling for approach, patient undergoing partial nephrectomy had lower rates of opioid use across all time periods examined and returned to work earlier than patients undergoing radical nephrectomy (partial vs. radical: −14.41 days; 95% CI, −21.22 to −7.60; p<0.01).

Conclusions

Patients undergoing various forms of surgery for kidney cancer had lower rates of peri-operative opioid use, fewer days of workplace absenteeism, but no difference in long-term rates of opioid use in patients undergoing minimally invasive as compared to open surgery.

Association of surgical approach and prolonged opioid prescriptions in patients undergoing major pelvic cancer procedures

BACKGROUND

The rise in deaths attributed to opioid drugs has become a major public health problem in the United States and in the world. Minimally invasive surgery (MIS) is associated with a faster postoperative recovery and our aim was to investigate if the use of MIS was associated with lower odds of prolonged opioid prescriptions after major procedures.

METHODS

Retrospective study using the IBM Watson Health Marketscan® Commerical Claims and Encounters Database investigating opioid-naïve cancer patients aged 18-64 who underwent open versus MIS radical prostatectomy (RP), partial colectomy (PC) or hysterectomy (HYS) from 2012 to 2017. Propensity weighted logistic regression analyses were used to estimate the independent effect of surgical approach on prolonged opioid prescriptions, defined as prescriptions within 91-180 days of surgery.

RESULTS

Overall, 6838 patients underwent RP (MIS 85.5%), 4480 patients underwent PC (MIS 61.6%) and 1620 patients underwent HYS (MIS 41.8%). Approximately 70-80% of all patients had perioperative opioid prescriptions. In the weighted model, patients undergoing MIS were significantly less likely to have prolonged opioid prescriptions in all three surgery types (Odds Ratio [OR] 0.737, 95% Confidence Interval [CI] 0.595-0.914, p = 0.006; OR 0.728, 95% CI 0.600-0.882, p = 0.001; OR 0.655, 95% CI 0.466-0.920, p = 0.015, respectively).

CONCLUSION

The use of the MIS was associated with lower odds of prolonged opioid prescription in all procedures examined. While additional studies such as clinical trials are needed for further confirmation, our findings need to be considered for patient counseling as postoperative differences between approaches do exist.

Comparing the Association Between Insurance and Mortality in Ovarian, Pancreatic, Lung, Colorectal, Prostate, and Breast Cancers

BACKGROUND

Insurance coverage is associated with better cancer outcomes; however, the relative importance of insurance coverage may differ between cancers. This study compared the association between insurance coverage at diagnosis and cancer-specific mortality (CSM; insurance sensitivity) in 6 cancers.

PATIENTS AND METHODS

Using the SEER cancer registry, data were abstracted for individuals diagnosed with ovarian, pancreatic, lung, colorectal, prostate, or breast cancer in 2007 through 2010. The association between insurance coverage at diagnosis and CSM was modeled using a Fine and Gray competing-risks regression adjusted for demographics. An interaction term combining insurance status and cancer type was used to test whether insurance sensitivity differed between cancers. Separate models were fit for each cancer. To control for lead-time bias and to assess whether insurance sensitivity may be mediated by earlier diagnosis and treatment, additional models were fit adjusting for disease stage and treatment.

RESULTS

Lack of insurance was associated with an increased hazard of CSM in all cancers (P<.01). The magnitude of the effect differed significantly between cancers (Pinteraction=.04), ranging from an adjusted hazard ratio of 1.13 (95% CI, 1.01-1.28) in ovarian and 1.19 (95% CI, 1.11-1.29) in pancreatic cancer to 2.19 (95% CI, 2.02-2.37) in breast and 2.98 (95% CI, 2.54-3.49) in prostate cancer. The benefit of insurance was attenuated after adjusting for stage and treatment (eg, screening/early treatment effect), with the largest reductions in prostate, breast, and colorectal cancers.

CONCLUSIONS

Greater insurance sensitivity was seen in screening-detected malignancies with effective treatments for early-stage disease (eg, prostate, breast, and colorectal cancers). Given that this differential is significantly reduced after adjusting for stage and treatment, our results suggest that a significant portion (but not all) of the benefit of insurance coverage is due to detection and treatment of certain curable early-stage cancers.

Contemporary Treatment Patterns for Non-muscle-invasive Bladder Cancer: Has the Use of Radical Cystectomy Changed in the BCG Shortage Era?

OBJECTIVE

To examine recent treatment trends for non-muscle-invasive bladder cancer (NMIBC), and specifically, to assess whether there was a change in use radical cystectomy (RC) between 2008 and 2015 using data from the Surveillance, Epidemiology, and End Results database.

METHODS

We identified patients presenting with high-grade T1 (T1HG) NMIBC at diagnosis during the study period. Treatment was dichotomized into "RC" and "local treatment" (which included transurethral resection and intravesical therapies). We then employed multivariable logistic regression models to assess the odds of undergoing RC across the study period. Additionally we examined the rates of RC for T1HG NMIBC during the period of BCG-shortage, defined as 2012-2015.

RESULTS

We identified 21,817 individuals diagnosed with T1HG bladder cancer during the study period. The majority of patients underwent local treatment (94.5%). During the shortage period, the rate of RC for T1HG NMIBC was significantly lower compared to the preshortage era (5.1% vs 5.9%, P = .007). Across the study period, the utilization of RC for T1HG NMIBC decreased significantly (odds ratio 0.99 per quarter, 95% confidence interval 0.98-0.99, P = .017).

CONCLUSION

In our cohort of patients diagnosed with T1HG bladder cancer, we found a significant decrease in the use of radical cystectomy across the study period. Contrary to the hypothesis of increasing rates of RC in the face of BCG shortage, the rate of RC was significantly higher in the pre-shortage era. Further examination of NMIBC treatment patterns will be necessary to assess the impact of BCG availability on therapeutic pathways and oncologic outcomes in patients with high-grade NMIBC.

Workplace absenteeism amongst patients undergoing open vs. robotic radical prostatectomy, hysterectomy, and partial colectomy

BACKGROUND

There is controversy regarding the widespread uptake of robotic surgery across several surgical disciplines. While it has been shown to confer clinical benefits such as decreased blood loss and shorter hospital stays, some argue that the benefits of this technology do not outweigh its high cost. We performed a retrospective insurance-based analysis to investigate how undergoing robotic surgery, compared to open surgery, may impact the time in which an employed individual returns to work after undergoing major surgery.

METHODS

We identified a cohort of US adults with employer-sponsored insurance using claims data from the MarketScan database who underwent either open or robotic radical prostatectomy, hysterectomy/myomectomy, and partial colectomy from 2012 to 2016. We performed multiple regression models incorporating propensity scores to assess the effect of robotic vs. open surgery on the number of absent days from work, adjusting for demographic characteristics and baseline absenteeism.

RESULTS

In a cohort of 1157 individuals with employer-sponsored insurance, those undergoing open surgery, compared to robotic surgery, had 9.9 more absent workdays for radical prostatectomy (95%CI 5.0 to 14.7, p < 0.001), 25.3 for hysterectomy/myomectomy (95%CI 11.0-39.6, p < 0.001), and 29.8 for partial colectomy (95%CI 14.8-44.8, p < 0.001) CONCLUSION: For the three major procedures studied, robotic surgery was associated with fewer missed days from work compared to open surgery. This information helps payers, patients, and providers better understand some of the indirect benefits of robotic surgery relative to its cost.

Inequity in selective referral to high-volume hospitals for genitourinary malignancies

INTRODUCTION

Compared to low-volume hospitals, high-volume hospitals are associated with lower rates of perioperative morbidity and mortality. However, access to high-volume hospitals is unequal. We investigated racial and socioeconomic disparities among patients undergoing surgery for genitourinary malignancies at high-volume hospitals.

MATERIAL AND METHODS

We queried the National Cancer Database from 2004-2015 to identify patients who underwent radical prostatectomy, radical cystectomy, and nephrectomy for nonmetastatic prostate cancer, muscle-invasive urothelial bladder cancer, and kidney cancer, respectively. Hospitals were ranked based on their annual volume for the given procedure. The endpoint of our study was receipt of treatment at a high-volume hospital. Multivariable logistic regression models were used to identify predictors of treatment at a high-volume hospital.

RESULTS

Our final cohort consisted of 397,242 prostate cancer patients, 39,480 bladder cancer patients, and 292,095 kidney cancer patients. For prostate and bladder cancer, Black race was associated with lower odds of treatment at a high-volume hospital (Odds Ratio [OR] 0.83, 95% confidence interval [CI] 0.79-0.87 and 0.71, 95%CI 0.58-0.87; reference: White). Higher education level and private insurance status were associated with greater odds of treatment across all 3 procedures (strongest effect for prostate cancer; higher education level: OR 1.63 [1.58-1.68]; private insurance 1.86 [1.77-1.97]). Moreover, an interaction was found between race and study period for all cancers examined (P < 0.001). Subgroup analyses revealed that Black patients were more likely to undergo radical prostatectomy at high-volume hospitals in 2013-2015 (OR 0.98, 95%CI 0.94-1.02) compared to 2004-2006 (OR 0.83, 95%CI 0.79-0.87).

CONCLUSION

Across all procedures, patients with lower education status and lack of insurance were less likely to be treated at high-volume hospitals. For prostate cancer and bladder cancer, Black race was a negative predictor of treatment at high-volume hospitals. Further studies are needed to understand the root causes for this inequity.

Minimally invasive cancer surgery is associated with a lower risk of venous thromboembolic events

BACKGROUND

Venous thromboembolism (VTE) is a significant source of postoperative morbidity and mortality in patients undergoing common oncologic procedures. We sought to estimate the effect of surgical approach on the risk of developing a VTE.

METHODS

IBM Watson Health Marketscan Database was used to conduct this retrospective study. In total, 12 938 patients who underwent either a radical prostatectomy, partial colectomy, or hysterectomy via a minimally invasive or open approach. We used a propensity-weighted logistic regression analysis to assess the independent effect of surgical approach on VTE. The primary outcome of interest was the 90-day rate of VTE after surgery.

RESULTS

Patients undergoing minimally invasive surgery across all three surgical procedures were noted to have a lower odds of developing a VTE: (radical prostatectomy, odds ratio [OR]: 0.667, 95% confidence interval [CI]: 0.500-0.891; P = .006 |partial colectomy: OR, 0.620, 95% CI: 0.477-0.805; P < .001| hysterectomy: OR, 0.549 95% CI: 0.353-0.854; P = .008).

CONCLUSION

We found that a minimally invasive approach was associated with significantly lower odds of VTE compared with undergoing the same open procedure. This study highlights how surgical approach may be an independent risk factor for development of VTE and may elucidate potential risk mitigation strategy.

Facility-Level Variation in Pelvic Lymphadenectomy During Radical Prostatectomy and Effect on Overall Survival in Men with High-Risk Prostate Cancer

PURPOSE

This study was designed to examine facility-level variation in the extent of pelvic lymphadenectomy and to determine whether more extensive lymphadenectomy is associated with a survival benefit among men with localized high-risk prostate cancer.

METHODS

Using data from the National Cancer Data Base, we identified 13,652 men with a high predicted probability of 10-year survival (≤ 65 years of age and Charlson Comorbidity Index score of 0) who underwent radical prostatectomy at 1023 facilities for biopsy-confirmed localized high-risk prostate cancer diagnosed between January 2004 and December 2011. Multilevel, multinomial logistic regression was fitted to predict facility-level probability of receiving different extents of lymphadenectomy. Inverse probability of treatment weighting-adjusted Cox regression model with Bonferroni correction was fitted to compare risk of overall mortality.

RESULTS

Overall, 11,284 (82.7%), 1601 (11.7%), and 767 (5.6%) men who underwent radical prostatectomy underwent concomitant none/limited lymphadenectomy (0-9 lymph nodes), standard lymphadenectomy (10-16 lymph nodes), and extended lymphadenectomy (≥ 17 lymph nodes), respectively. Extended lymphadenectomy was not associated with a survival benefit relative to standard lymphadenectomy (hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.48-1.23; p = 0.4) nor no/limited lymphadenectomy (HR 0.77, 95% CI 0.87-2.20; p = 0.29) at a median follow-up of 83.3 months. Risk-adjusted facility-level predicted probabilities of extended, standard, or no/limited lymphadenectomy ranged from 0.01 to 52.6%, 3.3-53.3%, and 17.8-96.3%, respectively.

CONCLUSIONS

We found significant facility-level variation in the extent of pelvic lymphadenectomy during radical prostatectomy despite no apparent survival benefit associated with more extensive lymphadenectomy. Further prospective data are needed to reevaluate the role of lymphadenectomy in the management of clinically localized prostate cancer.

Adoption of immunotherapy in the community for patients diagnosed with metastatic melanoma

BACKGROUND

The introduction of immune checkpoint inhibitors has led to a survival benefit in patients with advanced melanoma; however data on the adoption of immunotherapy in the community are scarce.

METHODS

Using the National Cancer Database, we identified 4725 patients aged ≥20 diagnosed with metastatic melanoma in the United States between 2011 and 2015. Multinomial regression was used to identify factors associated with the receipt of treatment at a low vs. high immunotherapy prescribing hospital, defined as the bottom and top quintile of hospitals according to their proportion of treating metastatic melanoma patients with immunotherapy.

RESULTS

We identified 246 unique hospitals treating patients with metastatic melanoma. Between 2011 and 2015, the proportion of hospitals treating at least 20% of melanoma patients with immunotherapy within 90 days of diagnosis increased from 14.5 to 37.7%. The mean proportion of patients receiving immunotherapy was 7.8% (95% Confidence Interval [CI] 7.47-8.08) and 50.9% (95%-CI 47.6-54.3) in low and high prescribing hospitals, respectively. Predictors of receiving care in a low prescribing hospital included underinsurance (no insurance: relative risk ratio [RRR] 2.44, 95%-CI 1.28-4.67, p = 0.007; Medicaid: RRR 2.10, 95%-CI 1.12-3.92, p = 0.020), care in urban areas (RRR 2.58, 95%-CI 1.34-4.96, p = 0.005) and care at non-academic facilities (RRR 5.18, 95%CI 1.69-15.88, p = 0.004).

CONCLUSION

While the use of immunotherapy for metastatic melanoma has increased over time, adoption varies widely across hospitals. Underinsured patients were more likely to receive treatment at low immunotherapy prescribing hospitals. The variation suggests inequity in access to these potentially life-saving drugs.

The impact of underinsurance on bladder cancer diagnosis, survival, and care delivery for individuals under the age of 65 years

BACKGROUND

Health insurance is a key mediator of health care disparities. Outcomes in bladder cancer, one of the costliest diseases to treat, may be especially sensitive to a patient's insurance status.

METHODS

The Surveillance, Epidemiology, and End Results registry and the National Cancer Data Base were used to identify individuals younger than 65 years who were diagnosed with bladder cancer from 2007 to 2014. The associations between the insurance status (privately insured, insured by Medicaid, or uninsured) and the following outcomes were evaluated: diagnosis with advanced disease, cancer-specific survival, delay in treatment longer than 90 days, treatment in a high-volume hospital, and receipt of neoadjuvant chemotherapy (NAC).

RESULTS

Compared with those with private insurance, uninsured and Medicaid-insured individuals were nearly twice as likely to receive a diagnosis of muscle-invasive bladder cancer (odds ratio [OR] for uninsured individuals, 1.90; 95% confidence interval [CI], 1.70-2.12; OR for Medicaid-insured individuals, 2.03; 95% CI, 1.87-2.20). They were also more likely to die of bladder cancer (adjusted hazard ratio [AHR] for uninsured individuals, 1.49; 95% CI, 1.31-1.71; AHR for Medicaid-insured individuals, 1.61; 95% CI, 1.46-1.79). Delays in treatment longer than 90 days were more likely for uninsured (OR, 1.36; 95% CI, 1.12-1.65) and Medicaid-insured individuals (OR, 1.22; 95% CI, 1.03-1.44) in comparison with the privately insured. Uninsured patients had lower odds of treatment at a high-volume facility, and Medicaid-insured patients had lower odds of receiving NAC (P < .001 for both).

CONCLUSIONS

Compared with privately insured individuals, uninsured and Medicaid-insured individuals experience worse prognoses and poorer care quality. Expanding high-quality insurance coverage to marginalized populations may help to reduce the burden of this disease.

Trends in Adherence to Thromboprophylaxis Guideline in Patients Undergoing Radical Cystectomy

OBJECTIVE

To examine the use of in-hospital pharmacologic thromboprophylaxis (PTP) in patients undergoing radical cystectomy between 2004 and 2014 and to assess the risk of venous thromboembolism (VTE) across the study period.

MATERIAL AND METHODS

We identified 8322 patients without contraindications to PTP undergoing radical cystectomy in the US using the Premier Healthcare Database. Nonparametric Wilcoxon type test for trend was employed to examine the trend of PTP utilization across the study period. Ensuing, we employed multivariable logistic regression and generalized linear regression models to examine the odds of receiving PTP and the risk of being diagnosed with VTE, respectively.

RESULTS

Based on VTE risk-stratification, the majority of patients (87.8%) qualified as "high-risk." Across the study period the use of PTP increased (Odds ratio 1.02, 95% confidence interval (CI) 1.00-1.03, P = .044), but remained underutilized as the maximum percentage of patients receiving in-hospital PTP did not exceed 58.6%. The risk of VTE did not vary across the study period (risk ratio 0.97, 95%CI 0.92-1.02, P = .178).

CONCLUSION

Utilization of PTP increased throughout the study period, while the risk of VTE did not change. Future studies are necessary to improve implementation of guideline-driven care, as PTP remained underutilized throughout the study period.

Variation in Positive Surgical Margin Status After Radical Prostatectomy for pT2 Prostate Cancer

INTRODUCTION

We evaluated patient, hospital, and cancer-specific factors associated with positive surgical margin (PSM) variability after radical prostatectomy in pT2 prostate cancer in the United States.

PATIENTS AND METHODS

A total of 45,426 men from 1152 hospitals with pT2 prostate cancer and known margin status after radical prostatectomy were identified using the National Cancer Database (2010-2015). Data on patient, cancer, hospital factors, and surgical approach were extracted. A mixed effects logistic regression model was computed to examine factors associated with PSM and partial R² values to assess the relative contributions of patient, cancer, and hospital variables to PSM status.

RESULTS

Median PSM rate of 8.5% (interquartile range, 5.2%-13.0%). Robotic (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.83-0.99) and laparoscopic (OR, 0.74; 95% CI, 0.64-0.90) surgical approach, academic institution (OR, 0.87; 95% CI, 0.76-1.00) and high hospital surgical volume (>297 cases [OR], 0.83; 95% CI, 0.70-0.99) were independently associated with a lower PSM. Black men (OR, 1.13; 95% CI, 1.01-1.26) and adverse cancer-specific features (prostate-specific antigen [PSA], 10-20; PSA >20; cT3 stage; Gleason 7, 8, 9-10; all P > .01) were independently associated with a higher PSM. Patient-specific, hospital-specific, and cancer-specific factors had a contribution of 2.3%, 3.9%, and 15.2%, respectively, to the variation in PSM. Facility had a contribution of 23.7% to the variation in PSM.

CONCLUSION

Cancer-specific factors account for 15.2% of PSM variation with the remaining 84.8% of PSM variation due to patient, hospital, and other factors not accounted within the model. Noncancer-specific factors represent addressable factors that are important for policy-makers in efforts to improve patient outcome.

Quality of Care in the Treatment of Localized Intermediate and High Risk Prostate Cancer at Minority Serving Hospitals

PURPOSE

We investigated the quality of care at minority serving hospitals compared to other institutions for men with localized intermediate and high risk prostate cancer.

MATERIALS AND METHODS

Using the National Cancer Database we identified 536,539 men 40 years old or older who presented with localized intermediate and high risk prostate cancer in the United States between 2004 and 2015. Institutions were ranked according to the proportion of black and Hispanic patients treated at a given institution, and the top decile institutions were defined as minority serving hospitals. We used multivariable analyses to characterize the association between minority serving hospitals and 3 end points, including receipt of definitive treatment, time to definitive treatment and receipt of androgen deprivation therapy in young (65 years or younger) and healthy (no comorbidity) men treated with external beam radiation therapy.

RESULTS

A total of 162 and 1,168 hospitals were defined as minority and nonminority serving hospitals, respectively. On multivariable analyses treatment at minority serving hospitals was associated with decreased odds of receiving definitive treatment (adjusted OR 0.73, 95% CI 0.62-0.85, p <0.001). Adjusted mean ± SE time to treatment was significantly longer at minority serving hospitals compared to nonminority serving hospitals (4.9 ± 2.2 days, p = 0.024). Among young and healthy men there was no association between treatment at a minority serving hospital and receipt of androgen deprivation therapy in conjunction with external beam radiation (AOR 0.90, 95% CI 0.75-1.09, p = 0.291).

CONCLUSIONS

Treatment at a minority serving hospital was associated with lower odds of receiving definitive therapy and longer time to definitive therapy for localized intermediate and high risk prostate cancer despite adjustment for race. This suggests that some racial disparities in prostate cancer may be explained by the sites at which racial and/or ethnic minorities receive care.

Performance and Impact of Prostate Specific Membrane Antigen-Based Diagnostics in the Management of Men with Biochemical Recurrence of Prostate Cancer and its Role in Salvage Lymph Node Dissection

Up to 50% of patients initially treated for prostate cancer in a curative intent experience biochemical recurrence, possibly requiring adjuvant treatment. However, salvage treatment decisions, such as lymph node dissection or radiation therapy, are typically based on prostate specific antigen (PSA) recurrence. Importantly, common imaging modalities (e.g., computed tomography [CT], magnetic resonance imaging, and bone scan) are limited and the detection of recurrent disease is particularly challenging if PSA is low. Prostate specific membrane antigen (PSMA) positron-emission tomography/computed tomography (PET/CT) is a novel and promising imaging modality which aims to overcome the incapability of early identification of distant and regional metastases. Within this review, we summarize the current evidence related to PSMA-PET/CT in prostate cancer men diagnosed with biochemical recurrence after local treatment with curative intent. We discuss detection rates of PSMA-PET/CT stratified by PSA-levels and its impact on clinical decision making. Furthermore, we compare different image-fusion techniques such as PSMA-PET vs. F-/C-Choline-PET scans vs. PSMA-single photon emission computed tomography/CT. Finally, we touch upon the contemporary role of radio-guided-PSMA salvage lymphadenectomy.

Mode of birth in twins: data and reflections

Our primary objective was to compare neonatal and maternal outcomes in women with twin pregnancies, beyond 32 weeks, having a planned vaginal birth or a planned caesarean section (CS). This was a retrospective cohort study from a single tertiary centre over nine years. 534 sets of twins ≥32 + 0 weeks of gestation were included. 401 sets were planned vaginally and 133 sets were planned by CS. We compared a composite adverse perinatal outcome (perinatal mortality or serious neonatal morbidity; five minute APGAR score ≤4, neurological abnormality and need for intubation) and a composite maternal adverse outcome (major haemorrhage, trauma or infection) between the groups. There were no significant differences. Given the similarity of these results with several other larger studies of twin birth, we sought to look at reasons why there is still a rising rate of CS for twin births. We further make suggestions for keeping this rate to a sensible minimum. Impact statement What is already known on this subject? The largest randomised controlled study comparing planned vaginal birth with planned CSs for lower risk twins between 32 and 39 weeks of gestation, showed no added safety from planned CS. However, in most of the Western countries this conclusion has failed to increase the number of planned vaginal births for lower risk twins. What do the results of this study add? This observational study from a single tertiary centre provides external validation of the twin trial results in a practical day-to-day setting. It also provides insights as to how planned vaginal birth can be developed and maintained, with a key focus on safety and maternal participation in decision making. It does focus on consent and providing accurate data. What are the implications of these findings for clinical practice and/or further research? There are good grounds to encourage vaginal birth for low-risk twin pregnancies. The trend of rising caesarean rates in low-risk twin pregnancies worldwide will erode important skills for the conduct of vaginal births without any clear benefit for mothers or babies. The current situation demands careful thought about implementing innovative training opportunities for younger obstetricians. Finally, we need intelligent responses to many non-evidence-based factors which can drive clinical practice.