Phase 1/2 Randomized Clinical Trial of In-clinic acupuncture Prior to Bacillus Calmette-Guérin in Patients with High-risk Non-muscle-invasive Bladder Cancer

BACKGROUND

Treatment-related dose-limiting dysuria and irritative bladder symptoms are common in patients receiving intravesical bacillus Calmette-Guérin (BCG) to treat non-muscle-invasive bladder cancer (NMIBC). Acupuncture has been shown to reduce pain and urinary urgency/frequency in other patient populations.

OBJECTIVE

To evaluate the feasibility, safety, and tolerability of weekly in-clinic preprocedural acupuncture among patients receiving induction BCG.

DESIGN, SETTING, AND PARTICIPANTS

Patients with high-risk NMIBC undergoing induction BCG were randomized 2:1 to a standardized acupuncture protocol (acupuncture) versus the standard-of-care control arm.

INTERVENTION

In-office acupuncture prior to each BCG instillation.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES

Feasibility was assessed via recruitment, retention, and intervention adherence. Acupuncture safety and tolerability were assessed via physician-reported Common Terminology Criteria for Adverse Events version 5.0 and adverse events (AEs). Secondary endpoints included BCG treatment adherence, patient-reported BCG-related toxicity, and bladder cancer-specific and generic (European Organisation for Research and Treatment of Cancer [EORTC]-QLQ-NMIBC-24 and EORTC-QLQ-NMIBC-C30) quality of life (QOL). Subjective assessments of acupuncture acceptability were performed through patient surveys.

RESULTS AND LIMITATIONS

A total of 43 individuals were randomized 2:1 to the acupuncture (n = 28) versus control (n = 15) group. The median age was 70.3 yr, and 76% were male. Week 7 follow-up surveys were completed by 93%; six participants withdrew early due to disease progression, refractory gross hematuria, or preference. Acupuncture was delivered successfully prior to each BCG treatment, with no acupuncture-related AEs or interruptions to induction BCG. BCG-attributed AEs were reported by 91% acupuncture and 100% control individuals, including pain (28% vs 43%, p = 0.34) and urinary symptoms (62% vs 79%, p = 0.31). Comparing acupuncture patients with controls, change in QOL over the study period demonstrated greater improvements in median urinary symptoms (9.5, interquartile range [IQR] 0.0-19.0 vs 0.0, IQR -14.3 to 7.1; p = 0.02) among patients in the acupuncture arm. Of the acupuncture patients, 96% reported that acupuncture was "very/extremely helpful," and 91% would recommend acupuncture to other patients. Limitations include modest sample size and single-institution design.

CONCLUSIONS

Acupuncture prior to induction BCG treatments is feasible and safe. In this phase 1/2 trial, improved urinary function scores were observed among patients undergoing acupuncture. Patients receiving acupuncture reported high degrees of satisfaction with treatments.

PATIENT SUMMARY

We evaluated the safety and feasibility of delivering acupuncture in a urology clinic prior to weekly intravesical bladder cancer treatments with bacillus Calmette-Guérin (BCG) in a randomized controlled trial. We found that acupuncture could be delivered safely prior to weekly BCG instillations and that the use of acupuncture was associated with high patient satisfaction and a decrease in patient-reported urinary symptoms compared with usual care.

Chronic Glucocorticoid Use and Risk for Advanced Prostate Cancer at Presentation: A SEER-Medicare Cohort Study

BACKGROUND

Examine the relationship between exposure to systemic glucocorticoids (steroids) and advanced prostate cancer (PCa) at presentation. Prior work suggested that steroid use may be associated with increased PCa risk.

MATERIALS AND METHODS

We queried the linked SEER-Medicare database (2004-2015) to identify PSA screened patients diagnosed with PCa. Criteria for screening included a PSA lab test or DRE exam in both the 12 month and 13 to 36 month periods prior to diagnosis of PCa. Steroid exposure was determined using Medicare Part D and groups were divided based on duration of use in the 3 years prior to diagnosis: controls with no exposure, <30 days, 30 days - 1 year, 1 to 2 years, and >2+ years. Advanced PCa was defined as systemic metastases or regional lymph node metastasis at presentation. Risk estimates for advanced PCa at presentation for steroid exposure groups vs. controls were assessed with univariable and multivariable logistic regression models.

RESULTS

We identified 22,920 PSA screened patients diagnosed with PCa of which 29% used glucocorticoids in the exposure period. The mean (SD) duration for glucocorticoid use (in days) among all steroid users was 76.7 days (192.1). On univariable and multivariable analyses, > 2 years of steroid exposure was associated with significantly increased risk for advanced PCa (OR 2.06, 95% CI 1.35-3.14 and OR 1.74, 95% CI 1.12-2.69, respectively).

CONCLUSION

In this population-based PSA-screened cohort, prolonged steroid use was associated with increased risk of advanced PCa at diagnosis. With the widespread use of glucocorticoids, it is important to consider the role steroids may play in PCa pathogenesis.

Isolating the Drivers of Racial Inequities in Prostate Cancer Treatment

BACKGROUND

Black individuals in the United States are less likely than White individuals to receive curative therapies despite a 2-fold higher risk of prostate cancer death. While research has described treatment inequities, few studies have investigated underlying causes.

METHODS

We analyzed a cohort of 40,137 Medicare beneficiaries (66 and older) linked to the Surveillance Epidemiology and End Results (SEER) cancer registry who had clinically significant, non-metastatic (cT1-4N0M0, grade group 2-5) prostate cancer (diagnosed 2010-2015). Using the Kitagawa-Oaxaca-Blinder decomposition, we assessed the contributions of patient health and health care delivery on the racial difference in localized prostate cancer treatments (radical prostatectomy or radiation). Patient health consisted of comorbid diagnoses, tumor characteristics, SEER site, diagnosis year, and age. Health care delivery was captured as a prediction model with these health variables as predictors of treatment, reflecting current treatment patterns.

RESULTS

A total of 72.1% and 78.6% of Black and White patients received definitive treatment, respectively, a difference of 6.5 percentage points. An estimated 15% [95% confidence interval (CI): 6-24] of this treatment difference was explained by measured differences in patient health, leaving the remaining estimated 85% (95% CI: 74-94) attributable to a potentially broad range of health care delivery factors. Limitations included insufficient data to explore how specific health care delivery factors, including structural racism and social determinants, impact differential treatment.

CONCLUSIONS

Our results show the inadequacy of patient health differences as an explanation of the treatment inequity.

IMPACT

Investing in studies and interventions that support equitable health care delivery for Black individuals with prostate cancer will contribute to improved outcomes.

Impact of Dobbs v. Jackson Women's Health Organization on Professional Decision-Making Among Urology Applicants

MATERIALS AND METHODS

An Institutional Review Board-exempt REDCap survey was distributed through the Society of Academic Urologists to all 508 applicants registered for the 2023 Urology Match following the rank list submission deadline on January 10, 2023. The survey closed on February 1, 2023. Responses were anonymized, aggregated, and characterized using descriptive statistics. Thematic mapping of open text comments was performed by 2 reviewers.

RESULTS

The response rate was 42% (215/508). Eighty-eight percent of respondents disapproved of the Dobbs ruling. Twenty percent of respondents (15% male/24% female) eliminated programs in states where abortion is illegal. Fifty-nine percent (51% male/70% female) would be concerned for their or their partner's health if they matched in a state where abortion was illegal, and 66% (55% male/82% female) would want their program to assist them or their partner if they required abortion care during residency. Due to the competitive nature of Urology, 68% of applicants reported feeling at least somewhat obligated to apply in states where abortion legislation conflicts with their beliefs. Of the 65 comments provided by respondents, 4 common themes emerged: (1) avoidance of states with restrictive abortion laws; (2) inability to limit applications because of the competitiveness of urology; (3) impacts on personal health care; and (4) desire for advocacy from professional urology organizations.

CONCLUSION

The Dobbs ruling will impact the urology workforce by affecting urology applicants' decision-making regarding residency selection and ranking. Although the competitiveness of the Urology Match pressures applicants to apply broadly, many are taking reproductive health care access into consideration.

Prostate cancer screening in African American men: a review of the evidence

BACKGROUND

Prostate cancer is the most diagnosed cancer in African American men, yet prostate cancer screening regimens in this group are poorly guided by existing evidence, given underrepresentation of African American men in prostate cancer screening trials. It is critical to optimize prostate cancer screening and early detection in this high-risk group because underdiagnosis may lead to later-stage cancers at diagnosis and higher mortality while overdiagnosis may lead to unnecessary treatment.

METHODS

We performed a review of the literature related to prostate cancer screening and early detection specific to African American men to summarize the existing evidence available to guide health-care practice.

RESULTS

Limited evidence from observational and modeling studies suggests that African American men should be screened for prostate cancer. Consideration should be given to initiating screening of African American men at younger ages (eg, 45-50 years) and at more frequent intervals relative to other racial groups in the United States. Screening intervals can be optimized by using a baseline prostate-specific antigen measurement in midlife. Finally, no evidence has indicated that African American men would benefit from screening beyond 75 years of age; in fact, this group may experience higher rates of overdiagnosis at older ages.

CONCLUSIONS

The evidence base for prostate cancer screening in African American men is limited by the lack of large, randomized studies. Our literature search supported the need for African American men to be screened for prostate cancer, for initiating screening at younger ages (45-50 years), and perhaps screening at more frequent intervals relative to men of other racial groups in the United States.

Interstate Telemedicine for Urologic Cancer Care

PURPOSE

US states eased licensing restrictions on telemedicine during the COVID-19 pandemic, allowing interstate use. As waivers expire, optimal uses of telemedicine must be assessed to inform policy, legislation, and clinical care. We assessed whether telemedicine visits provided the same patient experience as in-person visits, stratified by in- vs out-of-state residence, and examined the financial burden.

MATERIALS AND METHODS

Patients seen in person and via telemedicine for urologic cancer care at a major regional cancer center received a survey after their first appointment (August 2019-June 2022) on satisfaction with care, perceptions of communication during their visit, travel time, travel costs, and days of work missed.

RESULTS

Surveys were completed for 1058 patient visits (N = 178 in-person, N = 880 telemedicine). Satisfaction rates were high for all visit types, both interstate and in-state care (mean score 60.1-60.8 [maximum 63], P > .05). More patients convening interstate telemedicine would repeat that modality (71%) than interstate in-person care (61%) or in-state telemedicine (57%). Patients receiving interstate care had significantly higher travel costs (median estimated visit costs $200, IQR $0-$800 vs median $0, IQR $0-$20 for in-state care, P < .001); 55% of patients receiving interstate in-person care required plane travel and 60% required a hotel stay.

CONCLUSIONS

Telemedicine appointments may increase access for rural-residing patients with cancer. Satisfaction outcomes among patients with urologic cancer receiving interstate care were similar to those of patients cared for in state; costs were markedly lower. Extending interstate exemptions beyond COVID-19 licensing waivers would permit continued delivery of high-quality urologic cancer care to rural-residing patients.

Inequities in Definitive Treatment for Localized Prostate Cancer Among Those With Clinically Significant Mental Health Disorders

INTRODUCTION

Patients with mental health disorders are at risk for receiving inequitable cancer treatment, likely resulting from various structural, social, and health-related factors. This study aims to assess the relationship between mental health disorders and the use of definitive treatment in a population-based cohort of those with localized, clinically significant prostate cancer.

METHODS

We conducted a cohort study analysis in SEER (Surveillance, Epidemiology, and End Results)-Medicare (2004-2015). History of a mental health disorder was defined as presence of specific ICD (International Classification of Diseases)-9 or ICD-10 diagnostic codes in the 2 years preceding cancer diagnosis. Descriptive statistics were performed using Wilcoxon rank-sum and χ2 testing. Multivariable logistic regression was used to evaluate the relationship between mental health disorders and definitive treatment utilization (defined as surgery or radiation).

RESULTS

Of 101,042 individuals with prostate cancer, 7,945 (7.8%) had a diagnosis of a mental health disorder. They were more likely to be unpartnered, have a lower socioeconomic status, and less likely to receive definitive treatment (61.8% vs 68.2%, P < .001). Definitive treatment rates were >66%, 62.8%, 60.3%, 58.2%, 54.3%, and 48.1% for post-traumatic stress disorder, depressive disorder, bipolar disorder, anxiety disorder, substance abuse disorder, and schizophrenia, respectively. After adjusting for age, race and ethnicity, marital status and socioeconomic status, history of a mental health disorder was associated with decreased odds of receiving definitive treatment (OR 0.74, 95% CI 0.66-0.83).

CONCLUSIONS

Individuals with mental health disorders and prostate cancer represent a vulnerable population; careful attention to clinical and social needs is required to support appropriate use of beneficial treatments.

Attitudes Among Society of Women in Urology Members Toward Dobbs v. Jackson Women's Health Organization

OBJECTIVE

To evaluate attitudes of women in urology regarding the Supreme Court ruling Dobbs v. Jackson Women's Health Organization, including impacts on personal/professional decision-making and the urology workforce.

METHODS

An IRB-exempt survey including Likert questions on participant views and free text questions was distributed to 1200 members of the Society of Women in Urology on 9/2/2022. Participants were medical students, urology residents, fellows, and practicing/retired urologists over 18. Responses were anonymous and aggregated. Quantitative responses were characterized with descriptive statistics and free-text responses were analyzed using thematic mapping. To complement this analysis, urologist density was mapped by county using 2021 National Provider Identifier data. State abortion laws were categorized based on Guttmacher Institute data on 10/20/2022. Data were analyzed using logistic regression, Poisson regression, and multiple linear regression.

RESULTS

329 respondents completed the survey. 88% disagree/strongly disagree with the Dobbs ruling. 42% of trainees may have changed their rank list if current abortion laws existed during their match. 60% of respondents said Dobbs will impact where they choose their next job. 61.5% of counties had zero urologists in 2021, 76% of which were in states with restrictive abortion laws. Urologist density was inversely associated with abortion law restrictiveness compared with the most protective counties.

CONCLUSION

The Dobbs ruling will significantly impact the urology workforce. Trainees may change how they rank programs in states with restrictive abortion laws, and urologists may consider abortion laws when choosing jobs. Restrictive states are at higher risk for worsening access to urologic care.

Patient-centered outcomes of telehealth for the care of rural-residing patients with urologic cancer

BACKGROUND

Patients residing in rural areas with urologic cancers confront significant obstacles in obtaining oncologic care. In the Pacific Northwest, a sizeable portion of the population lives in a rural county. Telehealth offers a potential access solution.

METHODS

Patients receiving urologic care through telehealth or an in-person appointment at the Fred Hutchinson Cancer Center in Seattle, Washington, were surveyed to assess appointment-related satisfaction and travel costs. Patients' residences were classified as rural or urban based on their self-reported ZIP code. Median patient satisfaction scores and appointment-related travel costs were compared by rural versus urban residence within telehealth and in-person appointment groups using Wilcoxon signed-rank or χ2 testing.

RESULTS

A total of 1091 patients seen for urologic cancer care between June 2019 and April 2022 were included, 28.7% of which resided in a rural county. Patients were mostly non-Hispanic White (75%) and covered by Medicare (58%). Among rural-residing patients, telehealth and in-person appointment groups had the same median satisfaction score (61; interquartile ratio, 58, 63). More rural-residing than urban-residing patients in the telehealth appointment groups strongly agreed that "Considering the cost and time commitment of my appointment, I would choose to meet with my provider in this setting in the future" (67% vs. 58%, p = .03). Rural-residing patients with in-person appointments carried a higher financial burden than those with telehealth appointments (medians, $80 vs. $0; p <.001).

CONCLUSIONS

Appointment-related costs are high among rural-residing patients traveling for urologic oncologic care. Telehealth provides an affordable solution that does not compromise patient satisfaction.

Sarcomatoid Urothelial Carcinoma Is Associated With Limited Response to Neoadjuvant Chemotherapy and Poor Oncologic Outcomes After Radical Cystectomy

INTRODUCTION

To examine oncologic outcomes and response to neoadjuvant chemotherapy (NAC) in patients with sarcomatoid urothelial carcinoma (SUC) treated with radical cystectomy (RC).

MATERIALS AND METHODS

We retrospectively queried our institutional database (2003-18) and Surveillance, Epidemiology, and End Results (SEER)-Medicare (2004-2015) for patients with cT2-4, N0-2, M0 SUC and conventional UC (CUC) treated with RC. Clinicopathologic characteristics were described using descriptive statistics (t test, χ2-test and log-rank-test for group comparison). Overall (OS) and recurrence-free-survival (RFS) after RC were estimated with the Kaplan Meier method and associations with OS were evaluated with Cox proportional hazards models.

RESULTS

We identified 38 patients with SUC and 287 patients with CUC in our database, and 190 patients with SUC in SEER-Medicare. In the institutional cohort, patients with SUC versus CUC had higher rates of pT3/4 stage (66% vs. 35%, P < 0.001), lower rates of ypT0N0 (6% vs. 35%, P = .02), and worse median OS (17.5 vs. 120 months, P < .001). Further, patients with SUC in the institutional versus SEER-Medicare cohort had similar median OS (17.5 vs. 21 months). In both cohorts, OS was comparable between patients with SUC undergoing NAC+RC vs. RC alone (17.5 vs. 18.4 months, P = .98, institutional cohort; 24 vs. 20 months, P = .56, SEER cohort). In Cox proportional hazards models for the institutional RC cohort, SUC was independently associated with worse OS (HR 2.3, CI 1.4-3.8, P = .001).

CONCLUSION

SUC demonstrates poor pathologic response to NAC and worse OS compared with CUC, with no OS benefit associated with NAC. A unique pattern of rapid abdominopelvic cystic recurrence was identified.

Early Pregnancy Loss Management in the Emergency Department vs Outpatient Setting

IMPORTANCE

Early pregnancy loss (EPL), or miscarriage, is the most common complication of early pregnancy, and many patients experiencing EPL present to the emergency department (ED). Little is known about how patients who present to the ED with EPL differ from those who present to outpatient clinics and how their management and outcomes differ.

OBJECTIVE

To compare the management and outcomes of patients with EPL who present to the ED vs outpatient clinics.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used the IBM MarketScan Research Database, a national insurance claims database. Participants were pregnant people aged 15 to 49 years in the US who presented to either an ED or outpatient clinic for initial diagnosis of EPL from October 2015 through December 2019. Data analysis was performed from May 2021 to March 2022.

EXPOSURES

The primary exposure was location of service (ED vs outpatient clinic). Other exposures of interest included demographic characteristics, current pregnancy history, and comorbidities.

MAIN OUTCOMES AND MEASURES

The primary outcome was EPL management type (surgical, medication, or expectant management). Complications, including blood transfusion and hospitalization, and characteristics associated with location of service were also evaluated. Bivariable analyses and multivariable logistic regression were used for data analysis.

RESULTS

A total of 117 749 patients with EPL diagnoses were identified, with a mean (SD) age of 31.8 (6.1) years. Of these patients, 20 826 (17.7%) initially presented to the ED, and 96 923 (82.3%) presented to outpatient clinics. Compared with the outpatient setting, patients in the ED were less likely to receive surgical (2925 patients [14.0%] vs 23 588 patients [24.3%]) or medication (1116 patients [5.4%] vs 10 878 patients [11.2%]) management. In the adjusted analysis, characteristics associated with decreased odds of active (surgical or medication) vs expectant management included ED (vs outpatient) presentation (adjusted odds ratio [aOR], 0.46; 95% CI, 0.44-0.47), urban location (aOR, 0.87; 95% CI, 0.82-0.91), and being a dependent on an insurance policy (vs primary policy holder) (aOR, 0.71; 95% CI, 0.67-0.74); whereas older age (aOR per 1-year increase 1.01; 95% CI, 1.01-1.01), established prenatal care (aOR, 2.35; 95% CI, 2.29-2.42), and medical comorbidities (aOR, 1.05; 95% CI, 1.02-1.09) were associated with increased odds of receiving active management. Patients in the ED were more likely than those in outpatient clinics to need a blood transfusion (287 patients [1.4%] vs 202 patients [0.2%]) or hospitalization (463 patients [2.2%] vs 472 patients [0.5%]), but complications were low regardless of location of service.

CONCLUSIONS AND RELEVANCE

In this cohort study of privately insured patients with EPL, differences in management between the ED vs outpatient setting may reflect barriers to accessing comprehensive EPL management options. More research is needed to understand these significant differences in management approaches by practice setting, and to what extent EPL management reflects patient preferences in both outpatient and ED settings.

Racial inequities in the quality of surgical care among Medicare beneficiaries with localized prostate cancer

BACKGROUND

US Black men are twice as likely to die from prostate cancer as men of other races. Lower quality care may contribute to this higher death rate.

METHODS

Sociodemographic and clinical data were obtained for men in Surveillance, Epidemiology, and End Results-Medicare diagnosed with clinically localized prostate cancer (cT1-4N0/xM0/x) and managed primarily by radical prostatectomy (2005-2015). Surgical volume was determined for facility and surgeon. Relationships between race, surgeon and/or facility volume, and characteristics of treating facility with survival (all-cause and cancer-specific) were assessed using multivariable Cox regression and competing risk analysis.

RESULTS

Black men represented 6.7% (n = 2123) of 31,478 cohort. They were younger at diagnosis, had longer time from diagnosis to surgery, lower socioeconomic status, higher prostate-specific antigen (PSA), and higher comorbid status compared with men of other races (p < .001). They were less likely to receive care from a surgeon or facility in the top volume percentile (p < .001); less likely to receive surgical care at a National Cancer Institute-designated cancer center and more likely seen at a minority-serving hospital; and less likely to travel ≥50 miles for surgical care. On multivariable analysis stratified by surgical volume, Black men receiving care from a surgeon or facility with lower volumes demonstrated increased risk of prostate cancer mortality (hazard ratio, 1.61; 95% confidence interval, 1.01-2.69) adjusting for age, clinical stage, PSA, and comorbidity index.

CONCLUSIONS

Black Medicare beneficiaries with prostate cancer more commonly receive care from surgeons and facilities with lower volumes, likely affecting surgical quality and outcomes. Access to high-quality prostate cancer care may reduce racial inequities in disease outcomes, even among insured men.

PLAIN LANGUAGE SUMMARY

Black men are twice as likely to die of prostate cancer than other US men. Lower quality care may contribute to higher rates of prostate cancer death. We used surgical volume to evaluate the relationship between race and quality of care. Black Medicare beneficiaries with prostate cancer more commonly received care from surgeons and facilities with lower volumes, correlating with a higher risk of prostate cancer death and indicating scarce resources for care. Access to high-quality prostate cancer care eases disparities in disease outcomes. Patient-centered interventions that increase access to high-quality care for Black men with prostate cancer are needed.

A multicenter study assessing survival in patients with metastatic renal cell carcinoma receiving immune checkpoint inhibitor therapy with and without cytoreductive nephrectomy

BACKGROUND

Cytoreductive nephrectomy (CN) for the treatment of metastatic renal cell carcinoma (mRCC) was called into question following the publication of the CARMENA trial. While previous retrospective studies have supported CN alongside targeted therapies, there is minimal research establishing its role in conjunction with immune checkpoint inhibitor (ICI) therapy.

OBJECTIVE

To evaluate the association between CN and oncological outcomes in patients with mRCC treated with immunotherapy.

MATERIALS AND METHODS

A multicenter retrospective cohort study of patients diagnosed with mRCC between 2000 and 2020 who were treated at the Seattle Cancer Care Alliance and The Ohio State University and who were treated with ICI systemic therapy (ST) at any point in their disease course. Overall survival (OS) was estimated using Kaplan Meier analyses. Multivariable Cox proportional hazards models evaluated associations with mortality.

RESULTS

The study cohort consisted of 367 patients (CN+ST n = 232, ST alone n = 135). Among patients undergoing CN, 30 were deferred. Median survivor follow-up was 28.4 months. ICI therapy was first-line in 28.1%, second-line in 17.4%, and third or subsequent line (3L+) in 54.5% of patients. Overall, patients who underwent CN+ST had longer median OS (56.3 months IQR 50.2-79.8) compared to the ST alone group (19.1 months IQR 12.8-23.8). Multivariable analyses demonstrated a 67% reduction in risk of all-cause mortality in patients who received CN+ST vs. ST alone (P < 0.0001). Similar results were noted when first-line ICI therapy recipients were examined as a subgroup. Upfront and deferred CN did not demonstrate significant differences in OS.

CONCLUSIONS

CN was independently associated with longer OS in patients with mRCC treated with ICI in any line of therapy. Our data support consideration of CN in well selected patients with mRCC undergoing treatment with ICI.

A Phase 1/2 Study of Rapamycin and Cisplatin/Gemcitabine for Treatment of Patients With Muscle-Invasive Bladder Cancer

INTRODUCTION

Cisplatin-based neoadjuvant chemotherapy (NAC) followed by cystectomy is the standard for muscle-invasive bladder cancer (MIBC), however, NAC confers only a small survival benefit and new strategies are needed to increase its efficacy. Pre-clinical data suggest that in response to DNA damage the tumor microenvironment (TME) adopts a paracrine secretory phenotype dependent on mTOR signaling which may provide an escape mechanism for tumor resistance, thus offering an opportunity to increase NAC effectiveness with mTOR blockade.

PATIENTS & METHODS

We conducted a phase I/II clinical trial to assess the safety and efficacy of gemcitabine-cisplatin-rapamycin combination. Grapefruit juice was administered to enhance rapamycin pharmacokinetics by inhibiting intestinal enzymatic degradation. Phase I was a dose determination/safety study followed by a single arm Phase II study of NAC prior to radical cystectomy evaluating pathologic response with a 26% pCR rate target.

RESULTS

In phase I, 6 patients enrolled, and the phase 2 dose of 35 mg rapamycin established. Fifteen patients enrolled in phase II; 13 were evaluable. Rapamycin was tolerated without serious adverse events. At the preplanned analysis, the complete response rate (23%) did not meet the prespecified level for continuing and the study was stopped due to futility. With immunohistochemistry, successful suppression of the mTOR signaling pathway in the tumor was achieved while limited mTOR activity was seen in the TME.

CONCLUSION

Adding rapamycin to gemcitabine-cisplatin therapy for patients with MIBC was well tolerated but failed to improve therapeutic efficacy despite evidence of mTOR blockade in tumor cells. Further efforts to understand the role of the tumor microenvironment in chemotherapy resistance is needed.

Spending and Out-of-Pocket Costs for Genital Gender-Affirming Surgery in the US

Importance

Genital gender-affirming surgery (GAS) is safe and offers substantial benefits to patients. Geographic accessibility and high out-of-pocket (OOP) costs reportedly hinder access; however, to date, this has not been thoroughly investigated at the national level.

Objective

To estimate OOP and total costs for GAS among commercially insured beneficiaries and assess whether costs differed between surgical procedures conducted in and outside the patient's state of residence.

Design, Setting, and Participants

This cross-sectional study used previously collected insurance data from the MarketScan Commercial Database (129 million patients) from January 1, 2007, to December 31, 2019. Vaginoplasties and phalloplasties were identified using diagnosis and procedure codes among patients aged 18 to 64 years. Out-of-state surgical procedures were identified based on residence at enrollment and place of service of the surgery. Data analysis took place from July 1 to September 31, 2021.

Exposures

Vaginoplasty and phalloplasty.

Main Outcomes and Measures

The main outcomes were differences in OOP and total costs by out-of-state designation, census region, age, and insurance type for surgical procedures, estimated using multivariable linear regression models.

Results

The study included 771 patients who underwent GAS. A total of 609 underwent vaginoplasty, of whom 249 (41%) underwent surgery in their state of residence (mean [SD] age, 38.7 [13.1] years) and 340 (56%) underwent surgery outside their state (mean [SD] age, 38.1 [13.0] years), and 162 underwent phalloplasty, of whom 66 (41%) underwent surgery in their state of residence (mean [SD] age, of 39.7 [11.6] years) and 81 (50%) underwent surgery outside their state (mean [SD] age, 35.8 [10.9] years); 20 vaginoplasties (3%) and 15 phalloplasties (9%) could not be classified as in or out of state owing to missing data about the facility or residence. Procedures outside the state were associated with 49% (95% CI, 19%-85%) higher OOP costs compared with procedures done in the state of residence.

Conclusions and Relevance

In this cross-sectional study, 56% of patients who underwent vaginoplasty and 50% of patients who underwent phalloplasty underwent the procedure outside their state of residence. Patients who underwent these procedures outside their state also experienced higher OOP costs than did those who underwent these procedures in their state. Improving geographic access and understanding patient preferences for surgical care may help reduce the cost burden for those planning to undergo GAS.

Aggressive Prostate Cancer at Presentation Following Solid Organ Transplantation

Solid organ transplant (SOT) candidates and recipients are often subject to intense screening regimens that can potentially delay transplantation and cause unnecessary harm. Although initial studies suggested that SOT recipients had elevated risk of prostate cancer (PCa), contemporary studies have shown that transplant recipients with low- or intermediate-risk PCa have similar outcomes to their counterparts without a transplant. However, there are limited data on the relationship between prior transplant exposure and the risk of clinically significant aggressive PCa at presentation. To provide additional insight, we queried the Surveillance, Epidemiology and End Results-Medicare database to establish a cohort of prostate-specific antigen (PSA)-screened transplant patients who then went on to develop PCa. Procedure and diagnosis codes were then used to identify patients with a history of SOT. Aggressive PCa phenotype was defined as death from PCa or de novo metastasis, regional lymph node metastasis, PSA >20 ng/l, or Gleason score 8–10 at presentation. On univariable and multivariable (adjusted for age and race) analyses, transplant patients (n = 292) were not at significantly higher risk of an aggressive prostate cancer phenotype with odds ratios of 0.95 (95% confidence interval 0.72–1.25) and 1.18, (95% confidence interval 0.90–1.57), respectively. The results suggest that transplant recipients can have similar screening protocols to those for the general population.

Patient summary

Using database results for transplant recipients, we investigated their risk of developing aggressive prostate cancer after transplantation. We found that having a transplant did not increase the risk of aggressive prostate cancer. This work suggests that transplant recipients are unlikely to benefit from more rigorous screening protocols than those for the general population.

Changes in body composition during neoadjuvant platinum-based chemotherapy associations prior to radical cystectomy: Implications for chemotherapy-associated adverse events and oncologic outcomes

476

Background: Low skeletal muscle index (SMI) is associated with an increased risk of mortality in muscle-invasive bladder cancer (MIBC) and chemotherapy-related adverse events (AE) across numerous other malignancies. Small case series suggest neoadjuvant chemotherapy (NAC) is associated with a significant decline in SMI in patients with MIBC. However, limited data exists regarding changes in fat mass during NAC. Herein, we examine changes in SMI, visceral fat index (VFI), and subcutaneous fat index (SFI) in patients receiving NAC for MIBC before radical cystectomy (RC). We describe associations between body composition changes and NAC-associated AE and all-cause mortality (ACM) in patients with MIBC. Methods: Retrospective review of patients with MIBC (≥pT2 N0/x/1 M0) who received NAC (2006-2019). Patients with digitized abdominal computed tomography scans (CT) within 75 days prior (T1) and 75 days following completion (T2) of NAC were included. We segmented and calculated the indices (cm2/m2) for SMI, VFI, and SFI at the third lumbar vertebra level at T1 and T2 using validated methodology. Associations with AE during NAC and ACM were evaluated with multivariate logistic regression and Cox proportional hazards models. Results: Included 170 patients, median age 63 years receiving a median of 4 (IQR 3-5) cycles of Gemcitabine/Cisplatin (52%), MVAC (28%), or other NAC (20%). Absolute and relative changes in SMI, VFI, and SFI over a median of 112 days (IQR 94-146) between measurements are presented in the Table. 117 (69%) patients experienced grade ≥3 chemotherapy-related AE. No associations between baseline body composition or change in body composition during NAC with chemotherapy-related AE. T1 SMI (HR: 0.98; 0.97-0.99, p = 0.008), as well as T2 SMI (HR: 0.98; 0.96-0.99, p = 0.003), T2 VFI (HR: 0.99; 0.99-1.0, p = 0.05) and T2 SFI (HR: 0.99; 0.98-1.0, P = 0.03) were associated with ACM after adjusting for age, clinical T and N stage, and performance status. Conclusions: Patients undergoing NAC prior to RC experienced a 6.4% decrease in SMI and a 5.2% decrease in VFI during an average of 112 days. Chemotherapy-related AE were not associated with a change in body composition. Baseline SMI and T2 SMI, SFI, and VFI were associated with ACM on multivariable analysis. Future work is needed to understand the mechanisms underpinning such changes and the extent to which potentially detrimental changes in body composition may be mitigated before surgery.[Table: see text]

Prospective evaluation of a comprehensive geriatric assessment (CGA) in multidisciplinary bladder cancer care: Feasibility and impact on decisional conflict

479

Background: Commonly utilized risk stratification tools demonstrate inconsistent associations with salient clinical outcomes in bladder cancer leading to a disproportionate reliance on providers’ subjective impression of a patient’s fitness for therapy. Current guidelines advocate for use of a CGA to quantify vulnerabilities in older ( > 65 years) patients before treatment selection. Our objective was to prospectively evaluate CGA in our Bladder Cancer Multidisciplinary Clinic (BCMC). We hypothesized that CGA implementation would be feasible and that discussion of the results during shared decision-making would be associated with reduced patient-reported decisional conflict. Methods: Patients seen in BCMC were prospectively enrolled from 6/1/20 to 7/20/21. In the first 3 months, participants underwent non-standardized risk stratification (“Routine cohort”, N = 27). Between 9/1/20 and 7/20/21, participants completed a CGA incorporating validated assessments of frailty, functional status, multimorbidity, nutrition, cognition, and mental health (“CGA cohort”, N = 67). Results were shared with patients during BCMC visits. All patients and providers (three physicians per clinic from: Uro-Oncology, Medical Oncology, and Radiation Oncology) completed a follow-up survey including the Decisional Conflict Scale (DCS). Time required to complete the CGA, completion rates, and patient-reported burden were assessed. Concordance of patient- and provider-reported decisional conflict was compared between Routine and CGA cohorts. Results: Of 138 eligible patients, 94 patients were successfully enrolled (68%) with median age of 72 years, ECOG PS ≥3 in 13%, and Charlson Comorbidity Index ≥3 in 18%, of whom 18% were women. Most patients had pT2 bladder cancer (87%; cN+ and M1 in 23.4% and 9.6%, respectively). CGA component completion rates were 79-100%. Survey response rates were high (patients: 77%, providers: 86%), and most (86%) patients felt that the CGA was, at most, minimally burdensome. Vulnerabilities detected across CGA domains triggered relevant referrals. Patient-reported median (IQR) DCS scores were numerically higher (e.g. greater decisional conflict) for the CGA cohort: (27 [14-33] vs 16 [2-30] for Routine patients, p = 0.28). Provider- and provider reported DCS score was correlated in the CGA (p = 0.04), but not the Routine cohort (p = 0.07). Conclusions: We prospectively evaluated use of CGAs in bladder cancer care and found that CGAs were successfully implemented with high rates of completion and low rates of perceived burden. Notably, in this pilot cohort of 94 patients, DCS scores did not differ significantly between patients and providers with CGA use. Future work will evaluate associations between individual instruments, treatment decisions, clinical outcomes and patient-reported quality of life measures.

Longitudinal patterns of urinary incontinence and associated predictors in women with type 1 diabetes

AIMS

Urinary incontinence (UI) in women is a dynamic condition with numerous risk factors yet most studies have focused on examining its prevalence at a single time. The objective of this study was to describe the long-term time course of UI in women with type 1 diabetes (T1D).

METHODS

Longitudinal data in women with T1D were collected from 568 women in the Epidemiology of Diabetes Interventions and Complications (EDIC) study, the observational follow-up of the Diabetes Control and Complications Trial (DCCT) cohort. Over a 12-year period, participants annually responded to whether they had experienced UI in the past year.

RESULTS

We identified four categories of UI in this population over time: 205 (36.1%) women never reported UI (no UI), 70 (12.3%) reported it one or two consecutive years only (isolated UI), 247 (43.5%) periodically changed status between UI and no UI (intermittent UI), and 46 (8.1%) reported UI continuously after the first report (persistent UI). Compared to women reporting no/isolated UI, women displaying the intermittent phenotype were significantly more likely to be obese (OR: 1.86, 95% CI 1.15, 3.00) and report prior hysterectomy (OR: 2.57, 95% CI: 1.39, 4.77); whereas women with persistent UI were significantly more likely to have abnormal autonomic function (OR: 2.36, 95% CI: 1.16-4.80).

CONCLUSIONS

UI is a dynamic condition in women with T1D. Varying risk factors observed for the different phenotypes of UI suggest distinctive pathophysiological mechanisms. These findings have the potential to be used to guide individualized interventions for UI in women with diabetes.

Efficacy of Platinum Rechallenge in Metastatic Urothelial Carcinoma After Previous Platinum-Based Chemotherapy for Metastatic Disease

BACKGROUND

Fit patients with metastatic urothelial carcinoma (mUC) receive first-line platinum-based combination chemotherapy (fPBC) as standard of care and may receive additional later-line chemotherapy after progression. Our study compares outcomes with subsequent platinum-based chemotherapy (sPBC) versus subsequent non-platinum-based chemotherapy (sNPBC).

MATERIALS AND METHODS

Patients from 27 international centers in the Retrospective International Study of Cancers of the Urothelium (RISC) who received fPBC for mUC and at least two cycles of subsequent chemotherapy were included in this study. A multivariable Cox proportional hazards model compared overall survival (OS) and progression-free survival (PFS).

RESULTS

One hundred thirty-five patients received sPBC and 161 received sNPBC. Baseline characteristics were similar between groups, except patients who received sPBC had higher baseline hemoglobin, higher disease control rate with fPBC, and longer time since fPBC. OS was superior in the sPBC group (median 7.9 vs 5.5 months) in a model adjusting for comorbidity burden, performance status, liver metastases, number of fPBC cycles received, best response to fPBC, and time since fPBC (hazard ratio, 0.72; 95% confidence interval, 0.53-0.98; p = .035). There was no difference in PFS. More patients in the sPBC group achieved disease control than in the sNPBC group (57.4% vs 44.8%; p = .041). Factors associated with achieving disease control in the sPBC group but not the sNPBC group included longer time since fPBC, achieving disease control with fPBC, and absence of liver metastases.

CONCLUSION

After receiving fPBC for mUC, patients who received sPBC had better OS and disease control. This may help inform the choice of subsequent chemotherapy in patients with mUC.

IMPLICATIONS FOR PRACTICE

Patients with progressive metastatic urothelial carcinoma after first-line platinum-based combination chemotherapy may now receive immuno-oncology agents, erdafitinib, enfortumab vedotin, or sacituzumab govitecan-hziy; however, those ineligible for these later-line therapies or who progress after receiving them may be considered for subsequent chemotherapy. In this retrospective study of 296 patients, survival outcomes and disease control rates were better in those receiving subsequent platinum-based rechallenge compared with non-platinum-based chemotherapy, suggesting that patients should receive platinum rechallenge if clinically able. Disease control with platinum rechallenge was more likely with prior first-line platinum having achieved disease control, longer time since first-line platinum, and absence of liver metastases.

The fluciclovine (FACBC) PET/CT site-directed therapy of oligometastatic prostate cancer (Flu-BLAST-PC) trial

TPS5099

Background: Patients with biochemical recurrence (BCR) after local definitive therapy for prostate cancer (PC) represent the largest group of patients alive with PC in the United States. For patients with BCR after both radical prostatectomy and radiation, no further definitive treatment options currently exist as standard of care. FACBC PET/CT is a next-generation imaging modality approved in 2016 for suspected PC recurrence based on elevated PSA levels following prior treatment. FACBC PET/CT allows for earlier detection at lower PSA levels of oligometastatic PC in patients who would otherwise be considered as having micro-metastatic disease. FACBC PET/CT may provide potential targets for site-directed therapy; however, it is unknown whether this approach leads to improvement in clinically relevant outcomes. Methods: Flu-BLAST-PC (ClinicalTrials.gov Identifier: NCT0417543) is a prospective, interventional study enrolling men with PC and BCR who have previously undergone both radical prostatectomy and adjuvant or salvage radiation to the prostatic fossa, with PSA ≥0.5 to < 10 ng/mL, PSA doubling time > 3 to < 18 months, and no radiographically detectable metastases by conventional CT and bone scan imaging. Enrolled patients undergo FACBC PET/CT imaging, and those with no PC metastases detected (Group 1) undergo observation with repeat FACBC PET/CT performed at PSA thresholds of > 2 and > 5 ng/mL, with eligibility for the trial ending at PSA ≥10 ng/mL if FACBC PET/CT remains negative. Those with 1-3 PC regions (defined as radiation fields) detected on FACBC PET/CT (Group 2) undergo site-directed therapy with surgery (e.g. lymphadenectomy) and/or radiation, as well as six months of systemic treatment with androgen deprivation therapy (ADT) and abiraterone acetate with prednisone. Patients with ≥4 PC regions detected on FACBC PET/CT (Group 3) undergo six months of ADT and abiraterone acetate with prednisone without any site-directed therapy. Patients initially in Group 1 who subsequently have PC metastases detected on repeat FACBC PET/CT imaging per protocol join Group 2 or Group 3 based on the number of PC regions involved. Given the long anticipated survival of patients with PC and BCR, the primary endpoint of the study is undetectable PSA ( < 0.2 ng/mL) rate in Group 2 at two years beyond study treatment, with secondary endpoints including the same outcome measure for Group 3, undetectable PSA rate two years after testosterone recovery from ADT in Groups 2 and 3, time to re-initiation of ADT, overall survival, and safety and tolerability. Assuming a null hypothesis of 15% undetectable PSA rate for patients with BCR two years after completing ADT and alternative hypothesis of improvement to 40% in Group 2, planned enrollment is 65 patients in Group 2. This will provide 90% power at the two-sided significance level of 0.05. Five patients have enrolled to date. Clinical trial information: NCT0417543.

Underutilization of Surgical Standard of Care for Insured Men with Invasive Penile Cancer

PURPOSE

Prior studies of mixed insurance populations have demonstrated poor adherence to surgical standard of care (SOC) for penile cancer. We used data from the Surveillance, Epidemiology and End Results (SEER) cancer registry linked to Medicare to calculate SOC adherence to surgical treatment of penile cancer in insured men over the age of 65, focusing on potential social and racial disparities.

METHODS

This is an observational analysis of patients with T2-4 penile cancer of any histologic subtype without metastasis in the SEER-Medicare database (2004-2015). SOC was defined as penectomy (partial or radical) with bilateral inguinal lymph node dissection (ILND) based on the National Comprehensive Cancer Network guidelines. We calculated proportions of those receiving SOC and constructed multivariate models to identify factors associated with receiving SOC.

RESULTS

A total of 447 men were included. Of these men, 22.1% (99/447) received SOC while 18.8% (84/447) received no treatment at all. Only 23.3% (104/447) had ILND while 80.9% (362/447) underwent total or partial penectomy. Race and socioeconomic status (SES) were not associated with decreased SOC. Increasing age (OR 0.93, 95%CI:0.89-0.96), Charlson Comorbidity Index score ≥ 2 (OR 0.53, 95%CI:0.29-0.97), and T3-T4 disease (OR 0.34, 95%CI:0.18-0.65) were associated with not receiving SOC on adjusted analysis.

CONCLUSIONS

Rates of SOC are low among insured men 65 years of age or older with invasive penile cancer, regardless of race or SES. This finding is largely driven by low rates of ILND. Strategies are needed to overcome barriers to SOC treatment for men with invasive penile cancer.

Efficacy of platinum re-challenge in metastatic urothelial carcinoma (mUC): A retrospective comparison of chemotherapy regimens

459

Background: First-line platinum-based combination chemotherapy (fPBC) is standard of care for fit patients with mUC. Further lines of therapy include immuno-oncology agents, erdafitinib, and enfortumab vedotin, but patients ineligible for these therapies or who subsequently progress may be considered for further chemotherapy. As the choice of chemotherapy regimen is unclear for these patients, we compared the efficacy of subsequent platinum-based chemotherapy (sPBC) and subsequent non-platinum-based chemotherapy (sNPBC) in patients with mUC. Methods: Data was analyzed from the Retrospective International Study of Cancers of the Urothelium (RISC), comprising patients from 28 international centers treated 2005-2012. Inclusion criteria were diagnosis of mUC, receipt of fPBC for mUC, and receipt of ≥2 cycles of subsequent chemotherapy. Patients who had received prior platinum-based chemotherapy in the non-metastatic setting were excluded. A multivariate Cox proportional hazards model was used to compare overall survival (OS), while χ2 and student’s t-test were used for univariate analyses. A two-sided p value of <0.05 was considered statistically significant. Results: Of 296 patients, 135 received sPBC and 161 received sNPBC. Common sNPBC regimens contained gemcitabine, taxanes, or pemetrexed. Baseline characteristics were similar, including Charlson Comorbidity Index (CCI) and performance status (PS), except more patients in the sPBC group had achieved investigator-designated stable disease or response (SD/R) with fPBC (75.4% vs. 63.3%, p = 0.031) and had higher hemoglobin values (median 11.9 vs. 11.1 g/dL, p = 0.004). OS was superior for patients receiving sPBC (median 7.9 months) compared to sNPBC (median 5.5 months) after adjusting for CCI, PS, presence of liver metastases, time since fPBC, and number of fPBC cycles received (HR 0.72, 95% CI 0.53-0.98, p = 0.035). 70 patients (57.4%) achieved SD/R with sPBC and 65 (44.8%) with sNPBC (p = 0.041). Achieving SD/R with subsequent chemotherapy was not associated with number of fPBC cycles received, but for sPBC was associated with longer time since fPBC (median 5.9 vs. 2.9 months, p = 0.033); the same was not true for sNPBC (median 2.2 vs. 2.6 months, p = 0.057). Achieving SD/R with fPBC was associated with greater likelihood of SD/R with sPBC (63.2% vs. 29.6%, p = 0.002), but not sNPBC (50.5% vs. 38.8%, p = 0.185). Liver metastases were negatively associated with likelihood of SD/R with sPBC (43.8% vs. 63.6%, p = 0.038), but not sNPBC (36.2% vs 49.0%, p = 0.147). Conclusions: After treatment with fPBC for mUC, patients able to receive sPBC had better OS compared to those who received sNPBC in a multivariate model. Patients were also more likely to achieve SD/R with sPBC; factors associated with achieving SD/R with sPBC but not sNPBC included longer interim since fPBC, achieving SD/R to fPBC, and absence of liver metastases.

Use of 18F-fluciclovine PET/CT (FluPET) for prostate cancer (PC): Initial results from a prospective registry at a tertiary academic center

29

Background: FluPET, a next-generation imaging modality approved in 2016 for suspected PC recurrence with elevated PSA after prior therapy, is becoming more widely available; however, practice patterns and impact on outcomes is unknown. We hypothesize FluPET is ordered for a variety of reasons, with findings often leading to changes in treatment plan. Methods: In this prospective registry, providers are surveyed before, 1-2 weeks after, and 1 year after FluPET to assess reasons for obtaining FluPET, projected treatment plan, changes in plan due to FluPET findings, and toxicity potentially attributable to change in treatment plan. Baseline patient characteristics, FluPET results, and longitudinal outcomes are collected. We report early descriptive findings with χ2 and student’s t-test used for univariate analyses. Results: 50 patients enrolled 12/2018-08/2020 had baseline characteristics described in Table; 46 underwent FluPET. Rationale for ordering included initial staging prior to definitive local therapy (6.1%), guidance of salvage local therapy for 1st biochemical recurrence (BCR) (46.9%), guidance of additional salvage after ≥2 local therapies and 2nd BCR (36.7%), and confirmation of equivocal metastatic disease (10.2%). When queried on next steps, providers considered observation (67.3%), androgen deprivation therapy (ADT) (26.5%), ADT + docetaxel or novel anti-androgens (AA) (20.4%), and salvage therapy with surgery, radiation, or cryotherapy (26.5%), often selecting ≥1 option. FluPET found ≥1 PC lesion in 73.9% of cases, ≥1 indeterminate lesion in 8.7%, and no lesions in 17.4%. 45.5% of providers reported changing treatment plan based on FluPET results; 6.8% changed to observation, 20.5% to systemic therapy, 13.6% to local salvage therapy, and 4.5% to a combination of local and systemic therapies. Change in therapy was associated with positive FluPET (54.5% vs. 18.2%, p=0.044), and within those cases, with higher SUVMax (mean 7.7 vs. 5.2, p=0.021) but not number of lesions (p=0.804). Conclusions: FluPET is often obtained to guide salvage therapy after BCR but is also used for initial staging or resolving equivocal findings of metastases. Many providers changed intended treatment based on FluPET findings, especially if positive; de-escalation to observation was rare. [Table: see text]

Treatment Trends and Cost Associated With Peyronie's Disease

INTRODUCTION

Providers may use several treatment options for patients with Peyronie's disease; however, it is unclear whether practice patterns have evolved over recent years and if this has impacted cost.

AIMS

To investigate trends in the treatment of Peyronie's disease over time and the associated costs using a national, commercial insurance claims database.

METHODS

A retrospective cohort study was conducted using claims from the Truven MarketScan database from 2007 to 2018 for men with Peyronie's disease. Cost was estimated as either the sum of prescription oral or injectable treatment costs or as the single net cost associated with the operative procedure.

MAIN OUTCOME MEASURES

Frequency of use of various treatments for Peyronie's disease and associated costs were assessed as trends over the timeline by year.

RESULTS

The estimated annual incidence of Peyronie's disease in this population rose from 61 to 77 per 100,000 patients over the included years, and the percent annual treatment rate rose from 17.8% to 26.2%. Colchicine was the most commonly prescribed oral agent in 2007 used in 22% of treated individuals; by 2018, pentoxifylline was the most common prescribed oral agent used in 33%. In 2007, 11% of treated patients received intralesional verapamil; however, by 2018, 24% received injectable collagenase, whereas <1% received intralesional verapamil. The mean annual, per-individual cost of Peyronie's disease treatment increased from $1,531 in 2007 to $10,339 in 2018. The cost increase was greatest for injectable therapies, which rose from $811 per individual in 2007 to $16,184 in 2018, a 19-fold increase.

CONCLUSIONS

Diagnosis and treatment of Peyronie's disease is increasing over time. Pentoxifylline has become the most common oral prescription, whereas injectable collagenase has become most common injection. The mean cost associated with Peyronie's disease treatment increased more than 5 times from 2007 to 2018 corresponding with Federal Drug Administration's approval of injectable collagenase. Loftus CJ, Rajanahally S, Holt SK, et al. Treatment Trends and Cost Associated With Peyronie's Disease. Sex Med 2020;8:673-678.

Abstract PO-211: Racial disparities in the quality of surgical care among Medicare beneficiaries with prostate cancer

Background: Black men in the US demonstrate a two-fold increase in prostate cancer mortality compared to men of other races/ethnicities. The aim of this analysis was to understand how access to high quality care—estimated using surgical volume— impacts disparities in prostate cancer mortality between Black and White men with localized prostate cancer. Methods: This is an analysis of a SEER-Medicare cohort of men diagnosed with localized prostate cancer (cT1-4N0M0) managed primarily by radical prostatectomy from 2005-2015. This analysis was restricted to Black and White men due to low representative numbers of men of other races/ethnicities.

Social, demographic, and clinical data were obtained. Both facility and provider data were obtained using administrative data in Medicare. Surgical volume for both providers and facilities were stratified into low, medium, and high. Simple descriptive analyses were performed. Multivariable Cox regression analyses was used to assess the relationship between race, surgical volume, and various clinical and social variables. Results: Black men represented 2,070 (7.1%) of the 29,071 men in this cohort. Black men in the cohort had a higher proportion of prostate specific antigen (PSA) greater than 20 ng/mL (7.0% vs 3.6%) and a higher proportion of men with cT1 disease at diagnosis (64.6% vs 56.1%) when compared to White men. Black men were also less likely to be married/partnered (63.5% vs. 79.9%), more likely to reside in an impoverished zip code (43.9% vs. 11.1%), and more likely to have significant comorbidities (7.2% vs. 2.9%). Black men in this cohort were most likely to be treated in the Southern US (42.8% of cases). Black men were more likely to be treated at a minority serving hospital/facility (24.6% vs. 3.1%, p &lt; 0.001), more likely to be treated at a very large hospital/health system (p &lt; 0.001), and less likely to be treated by a high-volume surgeon or facility (7.7% vs. 19.9%, p &lt; 0.001) compared to White men. On multivariable analysis adjusted for race, hospital type, NCI comorbidity index, clinical stage, and prostatectomy volume; black men demonstrated an increased risk of prostate cancer mortality (hazard ratio 1.27, 95% CI 0.94, 1.72) compared to White men. On stratified analysis, there were no racial disparities in cancer-specific mortality among men treated by a high-volume provider/facility. In contrast, Black men treated by a low/medium volume provider/facility had a higher likelihood of prostate cancer related death following surgery (hazard ratio 1.41, 95% CI 1.02, 1.95, p = 0.04). Conclusions: Black Medicare beneficiaries with prostate cancer demonstrate unique patterns of surgical care utilization, with differences noted in the types and surgical volumes—and likely surgical quality—of their health facilities and providers. Our findings suggest that access to high-quality prostate cancer care is an important mediator of racial disparities in prostate cancer, even among men with access to health insurance.

Citation Format: Yaw A. Nyame, Sarah K. Holt, Ruth Etzioni, John L. Gore. Racial disparities in the quality of surgical care among Medicare beneficiaries with prostate cancer [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-211.

Response to Neoadjuvant Chemotherapy and Survival in Micropapillary Urothelial Carcinoma: Data From a Tertiary Referral Center and the Surveillance, Epidemiology, and End Results (SEER) Program

BACKGROUND

Micropapillary urothelial carcinoma (MPC) is a rare urothelial carcinoma variant with conflicting data guiding clinical practice. In this study, we explored oncologic outcomes in relation to neoadjuvant chemotherapy (NAC) in a retrospective cohort of patients with MPC, alongside data from Surveillance, Epidemiology, and End Results (SEER)-Medicare.

PATIENTS AND METHODS

We retrospectively identified patients with MPC or conventional urothelial carcinoma (CUC) without any variant histology undergoing radical cystectomy (RC) in our institution (2003-2018). SEER-Medicare was also queried to identify patients diagnosed with MPC (2004-2015). Clinicopathologic data and treatment modalities were extracted. Overall survival (OS) was estimated with the Kaplan-Meier method. Mann-Whitney-Wilcoxon and chi-square tests were used for comparative analysis and Cox regression for identifying clinical covariates associated with OS.

RESULTS

Our institutional database yielded 46 patients with MPC and 457 with CUC. In SEER-Medicare, 183 patients with MPC were identified, and 63 (34%) underwent RC. In the institutional cohort, patients with MPC had significantly higher incidence of cN+ (17% vs. 8%), pN+ stage (30% vs. 17%), carcinoma-in-situ (43% vs. 25%), and lymphovascular invasion (30% vs. 16%) at RC versus those with CUC (all P < .05). Pathologic complete response (ypT0N0) to NAC was 33% for MPC and 35% for CUC (P = .899). Median OS was lower for institutional MPC versus CUC in univariate analysis (43.6 vs. 105.3 months, P = .006); however, MPC was not independently associated with OS in the multivariate model. Median OS was 25 months in the SEER MPC cohort for patients undergoing RC, while NAC was not associated with improved OS in that group.

CONCLUSION

Pathologic response to NAC was not significantly different between MPC and CUC, while MPC histology was not an independent predictor of OS. Further studies are needed to better understand biological mechanisms behind its aggressive features as well as the role of NAC in this histology variant.

Gender Differences in Authorship in Urology: a Five-year Review of Publications in Five High-impact Journals

OBJECTIVE

To describe the proportions of peer-reviewed manuscripts authored by women in 5 high-impact, widely available urology journals, and to compare these to the proportion of women in urology. About 9% of attending urologists and 25% of urology residents are women. We hypothesized that women comprised fewer than 25% of first authors and fewer than 10% of last/senior authors.

METHODS

We searched peer-reviewed original manuscripts in the Journal of Urology, Journal of Pediatric Urology, Neurourology and Urodynamics, Urology, and Urologic Oncology from January 2014 to June 2019. First and last author gender identity was recorded. Observed and expected proportions and temporal trends were compared, with findings considered statistically significant at P < .05.

RESULTS

Of 8653 multiple-author papers, 2275 (26.3%) had women as first authors, paralleling the current proportion of women in training (P = .98). Women were senior/last authors in 1255 (14.5%) papers; this was higher than the current proportion of female urologists in practice (P < .0001) for all journals but NAU (P = .59). Only 527 (6.1%) of multiple-author papers had both female first and last authors whereas 5640 (65.3%) of papers had both male first and last authors. The first author was more likely female when the senior author was female (OR = 2.34, 95% CI: 2.06-2.65); most female-first and -last authored manuscripts were published in subspecialty journals and those utilizing double-blind peer review.

CONCLUSION

The proportion of female first- and senior-authored manuscripts is significantly higher than the proportion of women in urology, and may reflect differential subspecialty choices and mentorship opportunities for women.

The Association Between 24-Hour Urine and Stone Recurrence Among High Risk Kidney Stone Formers: A Population Level Assessment

OBJECTIVE

To determine if obtaining a 24-hour urine collection (24HU) in stone formers is associated with decreased recurrent stone episodes.

METHODS

Using the MarketScan database, adults 17-62 years old with nephrolithiasis were identified between 2007 and 2017 with a minimum of 3-year follow up. High-risk stone formers, those undergoing stone surgery, and those with history of recurrent stones were identified. The exposure was a 24HU within 6 months of primary diagnosis. The outcome was recurrent stone episodes-defined by stone-related emergency room visits, hospitalizations, or stone surgery 90 days to 3 years after diagnosis. Logistic regression was used to estimate recurrence risk by 24HU exposure for the overall cohort and sub-cohorts limited to known recurrent stone formers, high-risk subjects, and those having stone surgery.

RESULTS

Of 434,055 subjects analyzed, 30,153 (6.9%) had a 24HU. An annual decline in 24HU utilization was seen (7.5%-5.8%). Regional variation in usage rate was also observed. On multivariate analysis, completing a 24HU was not associated with risk of recurrence in any of the following cohorts: recurrent stone formers (OR 0.98, 95% CI 0.9-1.07), both high risk and recurrent stone formers (OR 0.95 [0.8-1.13]), those undergoing surgery (OR 1.02 [0.97-1.07]); a positive association with 24HU and recurrence was seen in those labeled high-risk (OR 1.08 [1.01-1.16]) and in all-comers (OR 1.15 [1.12-1.19]).

CONCLUSION

The 24HU was not associated with decreased recurrence rates in the overall population nor in higher risk sub-cohorts.

Treatment of metastatic recurrence of urothelial carcinoma after previous cisplatin-based chemotherapy: A retrospective comparison of different chemotherapy regimens

e17005

Background: The optimal choice of first-line chemotherapy for urothelial carcinoma (UC) patients who recur after previous cisplatin-based chemotherapy for locally-advanced disease is unclear. Our objective is to compare the efficacy of platinum (PBC) versus non-platinum (NPBC) based first-line chemotherapy regimens for such patients after metastatic recurrence. Methods: Data was collected from the Retrospective International Study of Cancers of the Urothelial Tract (RISC), a database consisting of patients with muscle-invasive or advanced UC from 28 centers between 2005 and 2012. Patient inclusion criteria included: 1) UC with no initial metastases (cT2-4, cN0-N3, and cM0), 3) receipt of cisplatin in the locally advanced setting, and 4) receipt of chemotherapy in the first-line metastatic setting. Overall survival (OS) was the primary endpoint. Secondary endpoints included progression-free survival (PFS) and response to chemotherapy. Kaplan-Meier and Cox regression models estimated OS, PFS, and response, adjusting for age, gender, Eastern Cooperative Oncology Group (ECOG-PS), Charlson comorbidity index (CCI), surgery, T and N stage, albumin, creatinine clearance, number of initial cisplatin cycles, and time from last chemotherapy. Results: 152 patients with metastatic UC (88 PBC and 64 NPBC) were analyzed. Twelve (7.9%) patients received local definitive radiation and 7 of these 12 also underwent cystectomy. The most common NPBC regimens included taxanes, gemcitabine, or pemetrexed. The median OS was 8.70 (95% CI: 7.53 to 11.16) and 10.27 months (95% CI: 7.37 to 13.10) for PBC and NPBC (HR: 1.04, 95% CI: .67 – 1.61, p = 0.86), respectively. Multivariable analysis showed an independent prognostic effect on OS for number of previous chemotherapy cycles (3-4 vs. 1-2) (HR: 0.44, 95% CI 0.20 – 0.96, P = 0.03) and whether surgery was performed (HR: 0.44, 95% CI 0.26 – 0.75, P = 0.003). Time from last chemotherapy was not prognostic for OS (HR: 0.99, 95% CI: 0.99 – 1.00, p = 0.19). There were no significant differences for both investigator-designated PFS (HR: 0.84, 95% CI: 0.57 – 1.24, p = .39) and response to chemotherapy between PBC and NPBC (p = 0.57). Conclusions: There is no significant outcome difference between PBC vs. NPBC in patients with metastatic-recurrent urothelial carcinoma who previously received cisplatin-based chemotherapy for locally advanced disease. Those who previously underwent radical surgery or who received 3-4 cycles of cisplatin had better OS with PBC.

Sarcomatoid urothelial carcinoma: Oncologic outcomes from a tertiary center and SEER-Medicare data

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Background: Sarcomatoid urothelial carcinoma (SUC) is a rare and aggressive bladder cancer variant with little evidence regarding prognostic characteristics and response to neoadjuvant chemotherapy (NAC). In this study, we delineate oncologic outcomes in patients with SUC after radical cystectomy (RC), presenting data from our institutional database and SEER-Medicare. Methods: We retrospectively queried our institutional database to identify consecutive patients with cT2-4 SUC and conventional (non-variant) UC (CUC) who underwent RC (2003-2018). SEER-Medicare database was also searched for patients with cT2-4 SUC (2004-2015). Clinicopathologic/treatment data were captured. Overall survival (OS – diagnosis to death) was estimated with the Kaplan-Meier method. T-test, χ2 test and log-rank test were used for group comparison analysis. Factors significant in univariate analysis for OS were included in the multivariate (MVA) Cox proportional hazards model. Results: Institutional RC database yielded 38 patients with SUC and 287 with CUC, while 190 patients with SUC were identified from SEER-Medicare [83 (44%) had RC]. Platinum-based NAC was given to 17/38 (45%), 162/287 (56%) and 26/83 (31%) patients, respectively. Institutional patients with SUC had significantly higher rates of pT3/4 disease at RC (66% vs. 35%, p < .001) and lower rates of complete pathologic response (ypT0N0) following NAC (6% vs 35%, p = .02). Median OS in patients who had RC was significantly inferior in our institutional SUC vs. CUC group (20 vs. 121 months, p < .001) and 21 months in the SEER-SUC cohort. No significant difference in OS was identified between NAC+RC vs. RC alone, both in the institutional (17 vs. 20 months, p = 0.66) and SEER-SUC cohort (24 vs. 20 months, p = 0.56). In MVA for the entire institutional cohort (SUC+CUC combined), SUC was independently associated with worse OS, when adjusted for advanced age, pT/N stage, performance status, NAC, lymphovascular invasion, surgical margins (HR, 95% CI: 2.3, 1.4 - 3.8, p = .001). Five patients had an abdomino-pelvic cystic recurrence, with median time to recurrence < 5 months. Conclusions: Patients with SUC treated with RC had high rates of extravesical extension, poor response to platinum-based NAC and worse OS compared to patients with CUC. Data from SEER showed a comparable OS to our SUC cohort. NAC was not associated with improved OS in any SUC cohort (institutional or SEER). A unique pattern of rapid abdomino-pelvic cystic recurrence, mimicking post-RC abdominal fluid collections, was also identified.

Skeletal muscle index and adverse events during a bladder cancer treatment episode

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Background: While sarcopenia is associated with increased mortality in bladder cancer, there is limited data in patients treated with neoadjuvant chemotherapy (NAC) that associates skeletal muscle index (SMI) and adverse treatment-associated outcomes. Herein, we evaluate associations between baseline SMI and severe adverse events (SAEs) during NAC and post-radical cystectomy (RC) 90-day Clavien ≥3 complications. Methods: SMI (cross sectional area of skeletal muscle, cm2 / height2, m2) was measured on an axial computed tomography (CT) image at the level of the third lumbar vertebral body, within 60 days prior to NAC and RC. Patients were classified as being sarcopenic, according to sex-specific consensus definitions: Male: SMI < 55, Female: SMI < 39. Associations with SAEs during NAC and 90-day Clavien grade 3-5 complications were assessed with multivariable logistic regression. Results: CT scans of sufficient quality (2005-18) were available for 143 patients. There were no significant differences in clinicopathologic characteristics between the study cohort and patients without available imaging (N = 261). Median SMI for men and women was 52.1 and 40.9 cm2/m2; 86 (60%) were sarcopenic. SAEs were observed in 92 patients (64%), resulting in hospitalization during NAC in 27 (19%), while 20 (14%) patients did not complete planned NAC due to SAEs. After adjusting for age, performance status, and clinical stage, SMI was not independently associated with NAC-associated SAEs. Postoperative complications occurred in 82 (57%) patients, including infectious complications (39; 27%), wound dehiscence (8; 6%), 90-day readmission (27; 19%). Wound healing complications including dehiscence, clinically significant hernia, urine leaks, or fistulae occurred in 33 (23%). While SMI was not independently associated with risk of complications overall (OR: 1.00, 95% CI: 0.96 - 1.03), it was associated with infectious complications (OR: 0.96, 95% CI: 0.92 - 0.99, p = 0.02), and wound dehiscence (OR: 0.93, 95% CI: 0.86 - 0.99, p = 0.02) with a trend towards significance for associations with any wound-healing complications (OR: 0.96, 95% CI: 0.91 - 1.00, p = 0.08). Conclusions: In the largest reported series of post-NAC patients with RC and detailed follow-up, pretreatment SMI was not associated with SAEs during NAC but was associated with serious infectious complications and wound dehiscence after RC. This data highlights the potential value in measuring SMI to identify patients at risk for select SAEs. Future studies should assess the benefit of prehabilitation before and during NAC.

Intravesical therapy and risk of cystectomy and bladder cancer death after BCG fails

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Background: Management of non-muscle-invasive bladder cancer (NMIBC) when BCG fails engages complex decision-making that incorporates consideration of radical cystectomy (RC) and several intravesical options. We sought to characterize trends in practice variation and health outcomes for patients receiving intravesical therapy and radical cystectomy for presumption of recurrent or progressive high-risk NMIBC that has failed BCG. Methods: We identified patients with high-risk NMIBC from SEER-Medicare diagnosed from 2004-2015 who completed a full dose of BCG treatment. We evaluated receipt of intravesical therapy after BCG fails based on a code for a transurethral resection of bladder tumor (TURBT) within 6 months of BCG treatment followed by a switch to a different intravesical agent, systemic therapy, or radical cystectomy. We constructed risk estimates for disease-specific survival and subsequent need for radical cystectomy and using the Kaplan-Meier method and multivariate Cox proportional-hazards models adjusted for competing risks of death and patient clinical/demographic factors. Results: Among high-risk NMIBC patients who received BCG in their first year of diagnosis (n = 14,369), 9.7% (n = 1,273) went on to receive intravesical therapy, 4.2% (n = 607) proceeded directly to cystectomy, 15.8% (n = 2,272) underwent re-induction with BCG, 7.0% (n = 1,009) initiated systemic chemotherapy and 4.4% died without receiving treatment after BCG. Median follow-up after the post-BCG recurrence was 29 months (IQR 42, 14-56). Those receiving intravesical therapy after BCG fails were older, had more comorbidities, resided in rural areas, and had higher proportion of clinical Ta cancers (p < 0.05 for all) compared with immediate RC patients. Intravesical agents after BCG fails are listed in the Figure. Among those undergoing intravesical therapy, 12.9% (n = 478) eventually underwent RC a median 13 months (IQR 20, 7-27) after treatment post-BCG (2-year cystectomy free survival 89.4% [95% CI 88.3-90.5%]). Actuarial 2-year and 5-year bladder cancer-specific survival was 84.0% (95% CI 82.3-85.7%) and 71.0% (95% CI 68.3-73.7%), respectively, after intravesical treatment post-BCG. Conclusions: The heterogeneity in treatments used for NMIBC that fails BCG indicates potential provider uncertainty in the management of this challenging clinical situation. The paucity of effective bladder-sparing therapies, which is reflected in a high 2-year risk of RC and bladder cancer-specific death, highlights the urgent need for new therapies in this patient population.

Patient-centered pathology reports for breast cancer care: Interim results of a randomized pilot study

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Background: Receiving a new cancer diagnosis event is a daunting event, quickly followed by complex decision-making between patients and care teams. In order for patients to fully engage in shared decision-making with their providers, they must have access to understandable, patient-centered information that empowers them to take an active role. Yet cancer pathology reports currently target providers and are marred by complex medical terminology. To address this gap, we designed and piloted patient-centered pathology reports (PCPRs) for breast cancer surgical pathology. We hypothesized that PCPRs would result in patients having greater pathology knowledge and decisional self-efficacy. Methods: PCPRs were designed with continuous guidance from breast surgeons, pathologists, and patient advocates with the goal of providing a supplemental tool to translate standard pathology reports to layman’s terms for patients. PCPRs were built into the electronic medical record and tested for quality and accuracy over a 4-month period. Participants were recruited from the clinical practices of two breast surgeons and randomized to receive either the PCPR and standard pathology report or standard pathology report alone. Patients were surveyed at baseline and one month after to assess their breast cancer knowledge and ratings of confidence (scale 1-5) and decisional self-efficacy (DSE) for treatment decision-making (scale 0-100). Results: Of a planned 40 pilot patients, 30 have been enrolled, randomized (20 standard report patients, 10 PCPR patients), and have follow up data. Evaluation of patient knowledge showed that compared with the control group, patients who received a PCPR had similar knowledge of the important elements of their report (p = 0.10-p = 0.69) with greater specificity for those report elements. Confidence in their diagnosis slightly favored PCPR recipients (confidence rating mean 4.00 vs. 3.77 for control patients, p = 0.67). Patients receiving the PCPR had better DSE immediately after receipt of the pathology report than standard report patients (DSE 96.0 vs. 82.2, respectively, p = 0.05) with a more attenuated DSE difference one month later (DSE 87.3 vs. 79.2, respectively, p = 0.35). Conclusions: This interim analysis suggests that providing breast cancer patients with patient-centered pathology reports may contribute to an improved ability to engage in shared decision-making. Confirming these results with complete pilot data could inform a larger multicenter study to validate their effectiveness in clinical cancer care.

Associations between baseline body composition and cancer-specific mortality following neoadjuvant chemotherapy and radical cystectomy for bladder cancer

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Background: Sarcopenia is a modifiable risk factor independently associated with cancer-specific mortality (CSM) in bladder cancer (BC). Sarcopenic obesity, where obesity is measured by fat mass index [FMI, total body fat (kg)/height(m)2], has been proposed as an additive insult. To date, studies have overwhelmingly been performed in patients treated without neoadjuvant chemotherapy (NAC). Herein, we evaluate associations between baseline skeletal muscle index (SMI), FMI, and CSM in patients treated with NAC and radical cystectomy (RC). Methods: Lumbar SMI (cross sectional area of skeletal muscle/height2, cm2/m2) was measured on a computed tomography (CT) image at the level of the third lumbar vertebral body, within 60 days prior to NAC. Total body FMI was calculated from visceral and subcutaneous fat cross-sectional areas. Patients were classified as being sarcopenic, according to sex-specific consensus definitions: Male: SMI < 55, Female: SMI < 39, and as obese if Male: FMI > 9, Female: > 13. Cancer-specific survival (CSS) was estimated using the Kaplan Meier method. Associations with CSM were summarized with multivariable Cox proportional hazards models. Results: 143 patients had CT scans of sufficient quality (2005-18). There were no significant differences in clinicopathologic characteristics between the study cohort and patients without available imaging (N = 261). Cisplatin-based NAC was given to 125 patients (87%), and 18 (13%) received other regimens. In total, 86 (60%) patients were sarcopenic, 52 (36%) obese, and 25 (17%) both sarcopenic and obese, while 48 (34%) were sarcopenic with normal FMI. Median follow-up was 2.7 years (IQR 1.2-6.2), and 43 patients died from BC. Three-year CSS was 61% (sarcopenic) vs. 77% (p < 0.05). Sarcopenic patients with normal FMI had the worst 3-year CSS (55%) compared to those with sarcopenia and FMI-obesity (79%), normal SMI with FMI-obesity (69%), and normal body composition (88%, p = 0.03). On multivariable analysis, neither FMI (HR: 0.77, 95% CI: 0.47-1.3, p = 0.3) nor SMI was independently associated with CSM (HR: 0.98, 95% CI: 0.96-1, p = 0.07) after adjustment for ASA score, pathologic tumor, and nodal stage. Conclusions: In patients treated with NAC+RC, pretreatment SMI trended towards independently predicting risk of CSM. Patients with sarcopenia and normal fat demonstrated the worst CSS. Further study is warranted on the impact of NAC on body composition and the role of the latter in risk stratification of this high-risk patient population.

Risk factors for orgasmic and concomitant erectile dysfunction in men with type 1 diabetes: a cross-sectional study

In this study, we sought to determine the burden and characteristics of orgasmic dysfunction (OD) and concomitant erectile dysfunction (ED) in men with type 1 diabetes (T1D) enrolled in the Epidemiology of Diabetes Interventions and Complications (EDIC) study. In 2010, we assessed orgasmic and erectile function using the International Index of Erectile Function (IIEF). Sociodemographic, clinical, and diabetes characteristics were compared by OD status (OD only, OD and ED, no ED or OD). Age-adjusted associations between risk factors and OD status were examined. OD and ED information was available from 563 men. Eighty-three men (14.7%) reported OD of whom 21 reported OD only and 62 reported OD and ED. Age-adjusted odds ratios demonstrated that men who reported OD only had higher odds of depression, low sexual desire, and decreased alcohol use compared with men reporting no dysfunction. Men with OD concomitant with ED had greater odds of elevated hemoglobin A1C, peripheral and autonomic neuropathy, and nephropathy. Men reporting both dysfunctions were also more likely to report smoking, lower urinary tract symptoms, and had greater odds of androgen deficiency than men with no sexual dysfunction. Men with longstanding T1D suffer from an increased burden of OD. Psychogenic factors predominate in men reporting OD only while men who present with concomitant ED report increased burden of diabetes severity, characteristics previously observed with incident ED. ED may be the central impediment to sexual function in men with OD and ED. Longitudinal studies to characterize OD and ED experience over time are warranted.

National Trends in CT Utilization and Estimated CT-related Radiation Exposure in the Evaluation and Follow-up of Stone Patients

OBJECTIVE

To describe trends in computed tomography (CT) use and estimate the radiation exposure among stone formers using a national insurance claims database.

METHODS

Within MarketScan, adult stone patients from 2007 to 2013 were identified using International Classification of Diseases-Revision 9, International Classification of Diseases-Revision 10, and Current Procedural Terminology codes. Patients were classified as "active" (≥2 diagnosis codes for nephrolithiasis, or receipt of stone surgery) or "inactive" (1 stone diagnosis) and compared to age- and gender-matched controls. CT utilization was tracked over 3 years for each group. Annual CT-related radiation exposure was estimated using previously published dose values and compared using Kruskal-Wallis and χ² tests. Demographic factors associated with greater CT exposure were identified on multivariate logistic regression.

RESULTS

Of active stone patients, 112,140 underwent surgery and 215,376 were managed nonoperatively. There were 175,228 inactive stone patients and 502,744 controls. On average, active stone patients received nearly 10 times as many CTs as controls at 3 years (P <.001), and more acute imaging (P <.001). About 25% and 15% of operative and nonoperative patients, respectively, received ≥3 CTs in 3 years. This was associated with female gender. For nonoperative patients, this was also associated with age, residence in the North-Central or South regions, and inversely associated with metropolitan residence (all P <.01). Over 10% of active stone patients are estimated to receive >20 mSv in the first year alone.

CONCLUSION

CT use and nonsurgical radiation exposure for active stone patients is significant. Over 10% are estimated to exceed occupational limits in the first year. Judicious CT imaging and low-dose protocols are critical for stone patients.

Genomic distinctions between metastatic lower and upper tract urothelial carcinoma revealed through rapid autopsy

BACKGROUND

Little is known about the genomic differences between metastatic urothelial carcinoma (LTUC) and upper tract urothelial carcinoma (UTUC). We compare genomic features of primary and metastatic UTUC and LTUC tumors in a cohort of patients with end stage disease.

METHODS

We performed whole exome sequencing on matched primary and metastatic tumor samples (N=37) from 7 patients with metastatic UC collected via rapid autopsy. Inter- and intra-patient mutational burden, mutational signatures, predicted deleterious mutations, and somatic copy alterations (sCNV) were analyzed.

RESULTS

We investigated 3 patients with UTUC (3 primary samples, 13 metastases) and 4 patients with LTUC (4 primary samples, 17 metastases). We found that sSNV burden was higher in metastatic LTUC compared to UTUC. Moreover, the APOBEC mutational signature was pervasive in metastatic LTUC and less so in UTUC. Despite a lower overall sSNV burden, UTUC displayed greater inter- and intra-individual genomic distances at the copy number level between primary and metastatic tumors than LTUC. Our data also indicate that metastatic UTUC lesions can arise from small clonal populations present in the primary cancer. Importantly, putative druggable mutations were found across patients with the majority shared across all metastases within a patient.

CONCLUSIONS

Metastatic UTUC demonstrated a lower overall mutational burden but greater structural variability compared to LTUC. Our findings suggest that metastatic UTUC displays a greater spectrum of copy number divergence from LTUC. Importantly, we identified druggable lesions shared across metastatic samples, which demonstrate a level of targetable homogeneity within individual patients.

Increasing use of neoadjuvant chemotherapy (NAC) in muscle-invasive bladder cancer (MIBC): Prognostic impact of non-standard of care (SOC) regimens

4532

Background: Cisplatin-based NAC can prolong overall survival (OS) in patients (pts) with MIBC. Utilization of NAC has increased to about 20% of pts with MIBC over the last decade. We evaluated NAC utilization with and without SOC cisplatin-based combination regimens and oncologic outcomes using registry data. Methods: This is a population-based analysis of linked SEER-Medicare data (2004-2011). We identified 4534 pts with MIBC (cT2-4N0-1) undergoing radical cystectomy (RC). Based on pharmacy records data, pts were stratified into 3 groups: SOC, non-SOC, and immediate cystectomy (IC). We used descriptive statistics to compare groups, and multivariate logistic regression to define factors associated with receiving SOC NAC. Competing risk bladder cancer-specific mortality (BCSM) incidence curves were generated and KM analysis was used to assess OS from time of RC. The impact of NAC on OS was evaluated with Cox regression analysis. Results: 694 (15.3%) pts received NAC, increasing from 11% in 2004 to 24.8% in 2011, with 345 (50%) receiving non-SOC, e.g. gemcitabine/carboplatin (49.3%), gemcitabine alone (21.2%), carboplatin alone (14.8%), cisplatin alone (8.4%), and methotrexate/vinblastine/ adriamycin/carboplatin (0.8%). On logistic regression, increasing age (OR 0.91, 95%CI 0.88 – 0.94, p < 0.0001), Hispanic/Latin ethnicity (OR 0.49, 95%CI 0.22 – 1.10, p = 0.08), and ≥moderate renal dysfunction (OR 0.20, 95%CI 0.08 – 0.51, p < 0.001) were associated with lower odds of SOC NAC. Non-SOC NAC was associated with higher BCSM (competing risk) and lower OS (KM) vs. IC and SOC NAC. On multivariable analysis, non-SOC NAC was associated with higher risk of BCSM (HR 1.35, 95%CI 1.06 – 1.72, p = 0.01) and lower OS (HR 1.38, 95%CI 1.11 – 1.70, p = 0.003) vs. SOC NAC. Conclusions: About 50% of pts receiving NAC were not treated with SOC regimens. Non-SOC NAC was associated with higher bladder cancer death risk. This stresses the role of SOC NAC ideally in a multidisciplinary expert setting, as well as the need for timely RC and neoadjuvant clinical trials, including cisplatin-ineligible pts.

Neoadjuvant chemotherapy utilization in muscle-invasive bladder cancer: Increasing yet inappropriate use?

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Background: Neoadjuvant cisplatin-based chemotherapy (NAC) is associated with improved overall survival in patients with muscle-invasive bladder cancer (MIBC); however, utilization nationally has been low. Over the past decade, the use of NAC has increased to approximately 20% of patients with MIBC. We investigate whether this increase in NAC is with appropriate cisplatin-based regimens using registry data. Methods: This is a population-based analysis of linked SEER-Medicare data from 2004-2011. We identified 4,534 patients with cT2-4N0-1 bladder cancer undergoing cystectomy. Specific chemotherapy drugs administered were identified using pharmacy records. The cohort was stratified into three groups, standard of care (SOC: i.e., appropriate cisplatin-based chemotherapy), non-SOC, and no NAC. Descriptive statistics were performed to compare each group and multivariate logistic regression performed to determine factors associated with receiving SOC NAC. Results: Over the study period, 694/4534 (15.3%) of patients in the study received NAC, increasing from 11.0% in 2004 to 24.8% in 2011. From 2004-2011, 345/694 (49.7%) of patients who were given NAC received a non-SOC regimen. Among patients that received non-SOC NAC, the most common regimens included gemcitabine-carboplatin in 170/345 (49.3%), gemcitabine monotherapy 73/345 (21.2%) carboplatin monotherapy in 51/345 (14.8%), cisplatin monotherapy 29/345 (8.4%), and MVA with carboplatin 3/345 (0.8%). On multivariate analysis, age (OR 0.91[95% CI 0.88-0.94]) and moderate/severe renal disease (OR 0.2[95% CI 0.08-0.51]) were negatively associated with SOC NAC. The year of diagnosis (OR 1.32[95% CI 1.23-1.42]) was positively associated with the receipt of SOC NAC in the cohort. Conclusions: Although NAC for MIBC has increased, nearly half of these patients are not receiving SOC cisplatin-based regimens. This underscores the importance of better identifying patients eligible for neoadjuvant therapy, the need for appropriate drug selection which may be facilitated through centers of excellence and multidisciplinary clinics, and the need for more clinical trials for cisplatin ineligible patients.

Chemotherapy regimen is associated with venous thromboembolism risk in patients with urothelial tract cancer

OBJECTIVE

To assess the association of venous thromboembolism (VTE) with different chemotherapy regimens in patients with urothelial tract cancer.

PATIENTS AND METHODS

We identified patients aged ≥66 years, diagnosed with urothelial tract cancer in the period 1998 to 2011 in the Surveillance, Epidemiology, and End Results (SEER) Medicare-linked database. The chemotherapy regimens analysed were gemcitabine/cisplatin (GC), methotrexate/vinblastine/doxorubicin/cisplatin (MVAC), or gemcitabine/carboplatin (CarboG). Propensity scores for treatment regimen based on comorbidities, tumour characteristics, age, and year of diagnosis were calculated. VTE rates within 120 days of chemotherapy initiation were calculated. VTE risk stratified by chemotherapy regimen was modelled using multivariable logistic regression, adjusting for treatment propensity scores and additional demographic characteristics. Overall survival stratified by VTE and chemotherapy regimen was estimated using Kaplan-Meier methods and the log-rank test.

RESULTS

Of 5594 identified patients, a VTE occurred in 13.0%. The VTE rates within 120 days of chemotherapy initiation were 15.3% for GC, 8.7% for MVAC, and 12.0% for CarboG. On multivariable analysis, MVAC (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.39-0.94) and CarboG (OR 0.71, 95% CI: 0.59-0.85) were associated with lower VTE risk compared with GC. VTE was associated with worse overall survival (P < 0.001).

CONCLUSIONS

Compared with GC, MVAC and CarboG were associated with a lower rate of VTE. This finding suggests that gemcitabine may add to the increased thrombosis risk from cisplatin. Additionally, patients with a VTE had worse survival outcomes than those without a VTE. Analysis of the risk of blood clots with different chemotherapy regimens in patients with urothelial tract cancer showed that GC was associated with the highest rate. We also found that blood clots were associated with worse patient outcomes.

Nonmuscle Invasive Bladder Cancer Influences Physical Health Related Quality of Life and Urinary Incontinence

OBJECTIVE

To evaluate the effects of nonmuscle invasive bladder cancer (NMIBC) on health-related quality of life (HRQOL) and urinary function within patients diagnosed with NMIBC as compared to the general population.

METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare Health Outcome Survey (SEER-MHOS) database (1998-2013), 325 patients diagnosed with NMIBC with baseline and postdiagnosis MHOS surveys were propensity-matched 1:5 to noncancer controls (NCC). Multivariate linear regression analysis compared NMIBC patients with matched NCC in terms of physical component summary (PCS), mental component summary (MCS), and health domain scales. Changes in urinary function were assessed using χ² testing.

RESULTS

Patients diagnosed with NMIBC experienced significant decline in PCS vs NCC (-3.0, 95% confidence interval [CI -4.1, -2.0] vs -1.5, 95%CI [-2.0, -1.0], P = .01), while the observed decline in MCS was not significantly different (P = .09) between groups. On sub-analysis, the significant decline in PCS was confined to patients with high-risk NMIBC (P = .01). NMIBC patients had significantly greater decline in role physical (P = .04), general health (P = .04) and role emotional (P <0.01) health domain scales. NMIBC patients were more likely to report worsened urinary leakage, require physician intervention, and receive new treatment for urinary leakage (P values all <.01).

CONCLUSION

NMIBC diagnosis was associated with significant decreases in physical HRQOL and urinary function compared with NCC. Further study focused on NMIBC patients, and the inherent HRQOL factors to this diagnosis is needed to assess where improvements can be made in treating this patient population.

Postoperative Imaging Patterns of Pediatric Nephrolithiasis: Opportunities for Improvement

PURPOSE

Imaging following surgical intervention for nephrolithiasis is important to define operative success and ensure the absence of silent obstruction. We assessed nationwide postoperative imaging patterns in children undergoing ureteroscopy and shock wave lithotripsy.

MATERIALS AND METHODS

We reviewed the MarketScan® Commercial Claims and Encounters database from 2007 to 2013 for patients 1 to 18 years old undergoing ureteroscopy or shock wave lithotripsy. We assessed imaging exposure following index procedure within 90 days as a primary analysis and 180 days as a secondary analysis of the index procedure. Univariate and multivariate statistical analyses were performed to assess factors associated with undergoing postoperative imaging.

RESULTS

A total of 4,251 children met inclusion criteria, of whom 1,647 had undergone shock wave lithotripsy and 2,604 had undergone ureteroscopy. Postoperative imaging was performed in 57.5% of the cohort, with a higher proportion of children undergong imaging following shock wave lithotripsy compared to ureteroscopy (73% vs 47.8%, p <0.001). Noncomputerized tomographic imaging modalities were most common following ureteroscopy (70.8%) and shock wave lithotripsy (84.6%). Younger children and those with complex medical conditions or complicated postoperative courses were more likely to undergo followup imaging. Computerized tomography was more commonly used in older children and females. At 180-day followup 63% of the cohort had undergone any imaging, again more frequently following shock wave lithotripsy (77.0%) vs ureteroscopy (45.0%).

CONCLUSIONS

A large percentage of children with nephrolithiasis do not undergo followup imaging after shock wave lithotripsy, and even fewer undergo imaging after ureteroscopy. Most followup imaging is done within 90 days of surgery. Further work is needed to define appropriate postoperative imaging practices in this population.

Burden of Urological Complications in Men and Women With Long-standing Type 1 Diabetes in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Cohort

OBJECTIVE

Type 1 diabetes has been associated with high rates of urinary and sexual problems, but the cumulative burden and overlap of these complications are unknown. We sought to determine prevalence of urological complications in persons with type 1 diabetes, associations with clinical and diabetes-related factors, and rates of emergence, persistence, and remission.

RESEARCH DESIGN AND METHODS

This ancillary longitudinal study among participants in the Diabetes Control and Complications Trial (DCCT) and observational follow-up study Epidemiology of Diabetes Interventions and Complications (EDIC) (652 women and 713 men) was conducted in 2003 and 2010/2011. Urinary incontinence (UI), lower urinary tract symptoms, urinary tract infection, female sexual dysfunction, erectile dysfunction, low male sexual desire, and orgasmic dysfunction were measured with validated instruments. Logistic regression determined association of complications with demographics and clinical characteristics.

RESULTS

Of sexually active women completing the 2010/2011 survey, 35% reported no complications, 39% had one, 19% two, 5% three, and 2% four. In men, 31% had no complications, 36% had one, 22% two, 9% three, and 3% four. Sexual dysfunction was most prevalent (42% women and 45% men) followed by UI in women (31%) and low sexual desire in men (40%). Urological complications were associated with age, BMI, and HbA_1c. Remission rates ranged from 4 to 12% over the 7-year interval between surveys.

CONCLUSIONS

Urological complications are prevalent and frequently co-occur in persons with type 1 diabetes. Remission rates in a minority subset indicate a rationale for future studies to mitigate the onset or impact of urological complications of diabetes.

Neonatal Circumcision and Urinary Tract Infections in Infants With Hydronephrosis

BACKGROUND

Boys with urinary tract abnormalities may derive a greater benefit from newborn circumcision for prevention of urinary tract infection (UTI) than the general population. However, the effect of newborn circumcision on UTI is not well characterized across the etiological spectrum of hydronephrosis. We hypothesized that boys with an early diagnosis of hydronephrosis who undergo newborn circumcision will have reduced rates of UTI.

METHODS

The MarketScan data set, an employer-based claims database, was used to identify boys with hydronephrosis or hydronephrosis-related diagnoses within the first 30 days of life. The primary outcome was the rate of UTIs within the first year of life, comparing circumcised boys with uncircumcised boys and adjusting for region, insurance type, year of birth, and infant comorbidity.

RESULTS

A total of 5561 boys met inclusion criteria, including 2386 (42.9%) undergoing newborn circumcision and 3175 (57.1%) uncircumcised boys. On multivariate analysis, circumcision was associated with a decreased risk of UTI in both boys with hydronephrosis and healthy cohorts: odds ratio (OR) 0.36 (95% confidence interval [CI] 0.29-0.44) and OR 0.32 (95% CI 0.21-0.48), respectively. To prevent 1 UTI, 10 patients with hydronephrosis would have to undergo circumcision compared with 83 healthy boys. Among specific hydronephrosis diagnoses, circumcision was associated with a reduced risk of UTI for those with isolated hydronephrosis (OR 0.35 [95% CI 0.26-0.46]), vesicoureteral reflux (OR 0.35 [95% CI 0.23-0.54]), and ureteropelvic junction obstruction (OR 0.35 [95% CI 0.20-0.61]).

CONCLUSIONS

Newborn circumcision is associated with a significantly lower rate of UTI among infant boys with hydronephrosis.