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Hendrickson WK, Allshouse AA, Nygaard IE, Swenson CW. Overactive Bladder in Late Pregnancy to 1 Year After First Vaginal Delivery. Urogynecology (Phila) 2024; 30:433-442. [PMID: 37903370 PMCID: PMC10987286 DOI: 10.1097/spv.0000000000001414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
IMPORTANCE Understanding overactive bladder (OAB) during pregnancy and postpartum may increase our knowledge of pathophysiology. OBJECTIVES The purpose of this study was to understand the prevalence and severity of OAB during pregnancy through 1 year postpartum as well as the associated factors. STUDY DESIGN This is a secondary analysis of a prospective cohort study evaluating primiparous women with a singleton term vaginal delivery assessed at the third trimester, 8 weeks postpartum, and 1 year postpartum. Overactive bladder was defined as urinary urgency plus nocturia or frequency, or urgency urinary incontinence (UUI). Overactive bladder severity was defined using average visual analog scores (0-100) from OAB symptoms on the Epidemiology of Prolapse and Incontinence Questionnaire. We evaluated associations with OAB at each time point using logistic regression. RESULTS Among 579 participants, mean age was 29 years. Overactive bladder prevalence was higher at 8 weeks postpartum (23%) than at the third trimester (18%, P = 0.03) and 1 year postpartum (19%, P = 0.03). Overactive bladder severity was higher at the third trimester (42.2) than at 8 weeks postpartum (23.3, P = 0.008), but not at 1 year postpartum (29.1, P = 0.1). In those with OAB, UUI severity was higher at 1 year postpartum compared with that at the third trimester ( P = 0.02). Younger age was associated with third trimester OAB. At 8 weeks postpartum, OAB was associated with older age, urinary tract infection after delivery, birth weight ≥3,500 g, and third trimester OAB. At 1 year postpartum, OAB was associated with birth weight ≥3,500 g and third trimester OAB. CONCLUSIONS Overactive bladder affects 1 in 5 primiparous women during pregnancy or after vaginal delivery. The increased severity of UUI postpartum and the association between higher birth weight and OAB postpartum suggest an effect of delivery.
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Affiliation(s)
- Whitney K. Hendrickson
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, UT
| | - Amanda A. Allshouse
- Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, UT
| | - Ingrid E. Nygaard
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, UT
| | - Carolyn W. Swenson
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah Health Sciences, Salt Lake City, UT
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Swenson CW, Hendrickson WK, Allshouse AA, Nygaard IE. Older maternal age at first vaginal delivery is associated with increased genital hiatus size at 1 year postpartum. Am J Obstet Gynecol 2024:S0002-9378(24)00062-0. [PMID: 38307470 DOI: 10.1016/j.ajog.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/18/2023] [Accepted: 01/20/2024] [Indexed: 02/04/2024]
Affiliation(s)
- Carolyn W Swenson
- Department of Obstetrics and Gynecology, The University of Utah, 30 N. Mario Capecchi Dr., Level 5 South, #237, Salt Lake City, UT 84112.
| | - Whitney K Hendrickson
- Department of Obstetrics and Gynecology, The University of Utah, 30 N. Mario Capecchi Dr., Level 5 South, #237, Salt Lake City, UT 84112
| | - Amanda A Allshouse
- Department of Obstetrics and Gynecology, The University of Utah, 30 N. Mario Capecchi Dr., Level 5 South, #237, Salt Lake City, UT 84112
| | - Ingrid E Nygaard
- Department of Obstetrics and Gynecology, The University of Utah, 30 N. Mario Capecchi Dr., Level 5 South, #237, Salt Lake City, UT 84112
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Hendrickson WK, Zhang C, Jelovsek JE, Nygaard IE, Presson AP. Reply by Authors. J Urol 2024; 211:142-143. [PMID: 38063172 DOI: 10.1097/ju.0000000000003746.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/29/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Whitney K Hendrickson
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Chong Zhang
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - J Eric Jelovsek
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Ingrid E Nygaard
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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Hendrickson WK, Zhang C, Jelovsek JE, Nygaard IE, Presson AP. Longitudinal Fluctuations in Treatment Response After OnabotulinumToxinA and Sacral Neuromodulation for Refractory Urgency Incontinence. J Urol 2024; 211:134-143. [PMID: 37871326 PMCID: PMC10842509 DOI: 10.1097/ju.0000000000003746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/29/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE We compared fluctuations in treatment response after onabotulinumtoxinA and sacral neuromodulation for urgency incontinence using Markov models. MATERIALS AND METHODS We fit data from a randomized trial to Markov models to compare transitions of success/failure over 6 months between 200 U onabotulinumtoxinA and sacral neuromodulation. Objective failure was <50% reduction in urgency incontinence episodes from baseline; subjective failure "strongly disagree" to "neutral" to the Patient Global Symptom Control questionnaire. RESULTS Of the 357 participants (median baseline daily urgency incontinence episodes 4.7 [IQR 3.7-6.0]) 61% vs 51% and 3.2% vs 6.1% reported persistent states of objective success and failure over 6 months after onabotulinumtoxinA vs sacral neuromodulation. Participants receiving onabotulinumtoxinA vs sacral neuromodulation had lower 30-day transition probabilities from objective and subjective success to failure (10% vs 14%, ratio 0.75 [95% CI 0.55-0.95]; 14% vs 21%, ratio 0.70 [95% CI 0.51-0.89]). The 30-day transition probability from objective and subjective failure to success did not differ between onabotulinumtoxinA and sacral neuromodulation (40% vs 36%, ratio 1.11 [95% CI 0.73-1.50]; 18% vs 17%, ratio 1.14 [95% CI 0.65-1.64]). CONCLUSIONS Over 6 months after treatment, 2 in 5 women's symptoms fluctuate. Within these initial 6 months, women receiving onabotulinumtoxinA transitioned from success to failure over 30 days less often than sacral neuromodulation. For both treatments, there was an almost 20%-40% probability over 30 days that women returned to subjective and objective success after failure. Markov models add important information to longitudinal models on how symptoms fluctuate after urgency incontinence treatment.
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Affiliation(s)
- Whitney K. Hendrickson
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
| | - Chong Zhang
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - J. Eric Jelovsek
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University, Durham, NC
| | - Ingrid E. Nygaard
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
| | - Angela P. Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
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Lai HH, Wiseman JB, Helmuth ME, Smith AR, Amundsen CL, Cameron AP, Glaser AP, Hendrickson WK, Kirkali Z, Kenton K. Phenotyping of Urinary Urgency Patients Without Urgency Incontinence, and Their Comparison to Urgency Incontinence Patients: Findings From the LURN Study. J Urol 2023; 209:233-242. [PMID: 36067368 PMCID: PMC9742334 DOI: 10.1097/ju.0000000000002939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 08/10/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE We characterize patients with urinary urgency with vs without urgency urinary incontinence who presented to clinics actively seeking treatment for their symptoms. MATERIALS AND METHODS Participants who enrolled in the Symptoms of Lower Urinary Tract Dysfunction Research Network were categorized into urinary urgency with vs without urgency urinary incontinence. Participants were followed for 1 year; their urinary symptoms, urological pain, psychosocial factors, bowel function, sleep disturbance, physical activity levels, physical function, and quality of life were compared. Mixed effects linear regression models were used to examine the relationships between urgency urinary incontinence and these factors. RESULTS Among 683 participants with urinary urgency at baseline, two-thirds (n=453) also had urgency urinary incontinence; one-third (n=230) had urinary urgency-only without urgency urinary incontinence. No differences were detected in urological pain between urinary urgency-only and urgency urinary incontinence. Those with urgency urinary incontinence had more severe urgency and frequency symptoms, higher depression, anxiety, perceived stress scores, more severe bowel dysfunction and sleep disturbance, lower physical activity levels, lower physical function, and worse quality of life than those with urinary urgency-only. Among those with urinary urgency-only at baseline, 40% continued to have urinary urgency-only, 15% progressed to urgency urinary incontinence, and 45% had no urgency at 12 months. Fifty-eight percent with urgency urinary incontinence at baseline continued to report urgency urinary incontinence at 12 months, while 15% improved to urinary urgency-only, and 27% had no urgency. CONCLUSIONS Patients with urgency urinary incontinence have severe storage symptoms, more psychosocial symptoms, poorer physical functioning, and worse quality of life. Our data suggested urgency urinary incontinence may be a more severe manifestation of urinary urgency, rather than urinary urgency and urgency urinary incontinence being distinct entities.
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Affiliation(s)
- H. Henry Lai
- Division of Urologic Surgery, Departments of Surgery and Anesthesiology, Washington University School of Medicine, St. Louis MO
| | | | | | | | - Cindy L. Amundsen
- Department of Obstetrics and Gynecology, Division of Urogynecology, Duke University, Durham NC
| | | | | | - Whitney K. Hendrickson
- Department of Obstetrics and Gynecology, Division of Urogynecology, Duke University, Durham NC
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda MD
| | - Kimberly Kenton
- Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine & Reconstructive Surgery, Northwestern University, Chicago IL
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Kowalski JT, Wiseman JB, Smith AR, Helmuth ME, Cameron A, DeLancey JOL, Hendrickson WK, Jelovsek JE, Kirby A, Kreder K, Lai HH, Mueller M, Siddiqui N, Bradley CS. Natural history of lower urinary tract symptoms in treatment-seeking women with pelvic organ prolapse; the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN). Am J Obstet Gynecol 2022; 227:875.e1-875.e12. [PMID: 35934118 PMCID: PMC9729365 DOI: 10.1016/j.ajog.2022.07.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/07/2022] [Accepted: 07/19/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND The association of pelvic organ prolapse with overactive bladder and other lower urinary tract symptoms, and the natural history of those symptoms are not well characterized. Previous cross-sectional studies demonstrated conflicting relationships between prolapse and lower urinary tract symptoms. OBJECTIVE This study primarily aimed to determine the baseline association between lower urinary tract symptoms and prolapse and to assess longitudinal differences in symptoms over 12 months in women with and without prolapse. Secondary aims were to explore associations between lower urinary tract symptoms and prolapse treatment. We hypothesized that: (1) prolapse is associated with the presence of lower urinary tract symptoms, (2) lower urinary tract symptoms are stable over time in patients with and without prolapse, and (3) prolapse treatment is associated with lower urinary tract symptom improvement. STUDY DESIGN Women enrolled in the Symptoms of Lower Urinary Tract Dysfunction Research Network Observational Cohort Study with adequate 12-month follow-up data were included. Prolapse and lower urinary tract symptom treatment during follow-up was guided by standard of care. Outcome measures included the Lower Urinary Tract Symptoms Tool total severity score (in addition to overactive bladder, obstructive, and stress urinary incontinence subscales) and Urogenital Distress Inventory-6 Short Form. Prolapse (yes or no) was defined primarily when Pelvic Organ Prolapse Quantification System points Ba, C or Bp were >0 (beyond the hymen). Mixed-effects models with random effects for patient slopes and intercepts were fitted for each lower urinary tract symptom outcome and prolapse predictor, adjusted for other covariates. The study had >90% power to detect differences as small as 0.4 standard deviation for less prevalent group comparisons (eg, prolapse vs not). RESULTS A total of 371 women were analyzed, including 313 (84%) with no prolapse and 58 (16%) with prolapse. Women with prolapse were older (64.6±8.8 vs 55.3±14.1 years; P<.001) and more likely to have prolapse surgery (28% vs 1%; P<.001) and pessary treatment (26% vs 4%; P<.001) during the study. Average baseline Lower Urinary Tract Symptoms Tool total severity scores were lower (fewer symptoms) for participants with prolapse compared with those without (38.9±14.0 vs 43.2±14.0; P=.036), but there were no differences in average scores between prolapse groups for other scales. For all urinary outcomes, average scores were significantly lower (improved) at 3 and 12 months compared with baseline (all P<.05). In mixed-effects models, there were no statistically significant interactions between pelvic organ prolapse measurement and visit and time-dependent prolapse treatment groups (P>.05 for all regression interaction coefficients). The Lower Urinary Tract Symptoms Tool obstructive severity score had a statistically significant positive association with Pelvic Organ Prolapse Quantification System Ba, Bp, and point of maximum vaginal descent. The Lower Urinary Tract Symptoms Tool total severity scale had a statistically significant negative association with Pelvic Organ Prolapse Quantification System Ba and point of maximum vaginal descent. No other associations between prolapse and lower urinary tract symptoms were significant (P>.05 for all regression coefficients). Symptom differences between prolapse groups were small: all regression coefficients (interpretable as additive percentage change in each score) were between -5 and 5 (standard deviation of outcomes ranged from 14.0-32.4). CONCLUSION Among treatment-seeking women with urinary symptoms, obstructive symptoms were positively associated with prolapse, and overall lower urinary tract symptom severity was negatively associated with prolapse. Lower Urinary Tract Symptoms Tool scores improved over 12 months regardless of prolapse status, including in those with treated prolapse, untreated prolapse, and without prolapse.
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Affiliation(s)
- Joseph T Kowalski
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA.
| | | | | | | | | | | | - Whitney K Hendrickson
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Anna Kirby
- University of Washington Medical Center, Seattle, WA
| | - Karl Kreder
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - H Henry Lai
- Division of Urologic Surgery, Departments of Surgery and Anesthesiology, Washington University School of Medicine, St. Louis, MO
| | - Margaret Mueller
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Catherine S Bradley
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA, and the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) Observational Cohort Study Group
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Hendrickson WK, Havrilesky L, Siddiqui NY. Cost-effectiveness of bacteriuria screening before urogynecologic surgery. Am J Obstet Gynecol 2022; 226:831.e1-831.e12. [PMID: 34922920 DOI: 10.1016/j.ajog.2021.11.1375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 11/17/2021] [Accepted: 11/25/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Currently, there is controversy over who requires preoperative screening for bacteriuria in the urogynecologic population and whether treating asymptomatic bacteriuria reduces postoperative urinary tract infection rates. OBJECTIVE To evaluate the cost-effectiveness of selective, universal, and no preoperative bacteriuria screening protocols in women undergoing surgery for prolapse or stress urinary incontinence. STUDY DESIGN A simple decision tree model was created from a societal perspective to evaluate cost and effectiveness of 3 strategies to prevent postoperative urinary tract infection: (1) a universal protocol where all women undergoing urogynecologic surgery are screened for bacteriuria and receive preemptive treatment if bacteriuria is identified; (2) a selective protocol, where only women with a history of recurrent urinary tract infection are screened and treated for bacteriuria; and (3) a no-screening protocol, where no women are screened for bacteriuria. Our primary outcome was the incremental cost-effectiveness ratio, calculated in cost per quality-adjusted life-years. Secondary outcomes were the number of urine cultures, postoperative urinary tract infections, and pyelonephritis associated with each strategy. Costs were derived from the Centers for Medicare & Medicaid Services, Healthcare Cost and Utilization Project, and Medical Expenditure Panel Survey. Clinical estimates were derived from published literature and data from a historic surgical cohort. Quality-of-life-associated utilities for urinary tract infection (0.73), pyelonephritis (0.66), and antibiotic use (0.964) were derived from the published literature using the HALex scale, reported directly by affected patients. One-way sensitivity analyses were performed over the range of reported values. RESULTS In the base case scenario, selective screening is more costly (no screen: $101.69, selective: $101.98) and more effective (no screen: 0.096459 quality-adjusted-life-year, selective: 0.096464 quality-adjusted-life-year) than no screening, and is cost-effective, with an incremental cost-effectiveness ratio of $49,349 per quality-adjusted-life-year. Both selective screening and no screening dominate universal screening in being less costly (universal: $111.92) and more effective (universal: 0.096446 quality-adjusted-life-year), with a slightly higher rate of postoperative urinary tract infection (no screen: 17.1%, selective: 16.9%, universal: 16.6%). In 1-way sensitivity analyses, selective screening is no longer cost-effective compared with no screening when the cost of a urine culture exceeds $12, cost of a preoperative urinary tract infection exceeds $93, the cost of a postoperative urinary tract infection is below $339, the specificity of a urine culture is less than 96%, or preoperative bacteriuria rates in those without symptoms but a history of recurrent urinary tract infection is <23%. Universal screening only becomes cost-effective when the postoperative urinary tract infection rate increases to >50% in those without risk factors and untreated preoperative bacteriuria. When compared with no screening, selective screening costs an additional $104 per urinary tract infection avoided and $2607 per pyelonephritis avoided. Compared with selective screening, universal screening costs $4609 per urinary tract infection avoided and $115,223 per pyelonephritis avoided. CONCLUSION Implementation of a selective preoperative bacteriuria protocol is cost-effective in most scenarios and associated with only a <1% increase in the 30-day postoperative urinary tract infection rate. No screening is cost-effective when cost of a preoperative urinary tract infection is high and the rate of preoperative bacteriuria in those without risk factors is low.
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Hendrickson WK, Xie G, Rahn DD, Amundsen CL, Hokanson JA, Bradley M, Smith AL, Sung VW, Visco AG, Luo S, Jelovsek JE. Predicting outcomes after intradetrusor onabotulinumtoxina for non-neurogenic urgency incontinence in women. Neurourol Urodyn 2022; 41:432-447. [PMID: 34859485 PMCID: PMC9014828 DOI: 10.1002/nau.24845] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/14/2021] [Accepted: 11/18/2021] [Indexed: 01/03/2023]
Abstract
AIMS Develop models to predict outcomes after intradetrusor injection of 100 or 200 units of onabotulinumtoxinA in women with non-neurogenic urgency urinary incontinence (UUI). METHODS Models were developed using 307 women from two randomized trials assessing efficacy of onabotulinumtoxinA for non-neurogenic UUI. Cox, linear and logistic regression models were fit using: (1) time to recurrence over 12 months, (2) change from baseline daily UUI episodes (UUIE) at 6 months, and (3) need for self-catheterization over 6 months. Model discrimination of Cox and logistic regression models was calculated using c-index. Mean absolute error determined accuracy of the linear model. Calibration was demonstrated using calibration curves. All models were internally validated using bootstrapping. RESULTS Median time to recurrence was 6 (interquartile range [IQR]: 2-12) months. Increasing age, 200 units of onabotulinumtoxinA, higher body mass index (BMI) and baseline UUIE were associated with decreased time to recurrence. The c-index was 0.63 (95% confidence interval [CI]: 0.59, 0.67). Median change in daily UUIE from baseline at 6 months was -3.5 (IQR: -5.0, -2.3). Increasing age, lower baseline UUIE, 200 units of onabotulinumtoxinA, higher BMI and IIQ-SF were associated with less improvement in UUIE. The mean absolute error predicting change in UUIE was accurate to 1.6 (95% CI: 1.5, 1.7) UUI episodes. The overall rate of self-catheterization was 17.6% (95% CI: 13.6%-22.4%). Lower BMI, 200 units of onabotulinumtoxinA, increased baseline postvoid residual and maximum capacity were associated with higher risk of self-catheterization. The c-index was 0.66 (95% CI: 0.61, 0.76). The three calculators are available at http://riskcalc.duke.edu. CONCLUSIONS After external validation, these models will assist clinicians in providing more accurate estimates of expected treatment outcomes after onabotulinumtoxinA for non-neurogenic UUI in women.
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Affiliation(s)
- Whitney K. Hendrickson
- Department of OBGYN, Division of Urogynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - Gongbo Xie
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina, USA
| | - David D. Rahn
- Department of OBGYN, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Cindy L. Amundsen
- Department of OBGYN, Division of Urogynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - James A. Hokanson
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Megan Bradley
- Department of Obstetrics, Gynecology and Reproductive Services, Division of Urogynecology and Pelvic Reconstructive Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ariana L. Smith
- Department of Surgery, Division of Urology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vivian W. Sung
- Department of OBGYN, Division of Urogynecology and Pelvic Reconstructive Surgery, Women and Infants Hospital, Brown University, Providence, Rhode Island, USA
| | - Anthony G. Visco
- Department of OBGYN, Division of Urogynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - Sheng Luo
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina, USA
| | - J. Eric Jelovsek
- Department of OBGYN, Division of Urogynecology, Duke University Medical Center, Durham, North Carolina, USA
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Harvie HS, Sung VW, Neuwahl SJ, Honeycutt AA, Meyer I, Chermansky CJ, Menefee S, Hendrickson WK, Dunivan GC, Mazloomdoost D, Bass SJ, Gantz MG. Cost-effectiveness of behavioral and pelvic floor muscle therapy combined with midurethral sling surgery vs surgery alone among women with mixed urinary incontinence: results of the Effects of Surgical Treatment Enhanced With Exercise for Mixed Urinary Incontinence randomized trial. Am J Obstet Gynecol 2021; 225:651.e1-651.e26. [PMID: 34242627 DOI: 10.1016/j.ajog.2021.06.099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 06/24/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Urinary incontinence is prevalent among women, and it has a substantial economic impact. Mixed urinary incontinence, with both stress and urgency urinary incontinence symptoms, has a greater adverse impact on quality of life and is more complex to treat than either stress or urgency urinary incontinence alone. Studies evaluating the cost-effectiveness of treating both the stress and urgency urinary incontinence components simultaneously are lacking. OBJECTIVE Cost-effectiveness was assessed between perioperative behavioral and pelvic floor muscle therapies combined with midurethral sling surgery and midurethral sling surgery alone for the treatment of women with mixed urinary incontinence. The impact of baseline severe urgency urinary incontinence symptoms on cost-effectiveness was assessed. STUDY DESIGN This prospective economic evaluation was performed concurrently with the Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence randomized trial that was conducted from October 2013 to April 2016. Participants included 480 women with moderate-to-severe stress and urgency urinary incontinence symptoms and at least 1 stress urinary incontinence episode and 1 urgency urinary incontinence episode on a 3-day bladder diary. The primary within-trial analysis was from the healthcare sector and societal perspectives, with a 1-year time horizon. Costs were in 2019 US dollars. Effectiveness was measured in quality-adjusted life-years and reductions in urinary incontinence episodes per day. Incremental cost-effectiveness ratios of combined treatment vs midurethral sling surgery alone were calculated, and cost-effectiveness acceptability curves were generated. Analysis was performed for the overall study population and subgroup of women with Urogenital Distress Inventory irritative scores of ≥50th percentile. RESULTS The costs for combined treatment were higher than the cost for midurethral sling surgery alone from both the healthcare sector perspective ($5100 [95% confidence interval, $5000-$5190] vs $4470 [95% confidence interval, $4330-$4620]; P<.01) and the societal perspective ($9260 [95% confidence interval, $8590-$9940] vs $8090 [95% confidence interval, $7630-$8560]; P<.01). There was no difference between combined treatment and midurethral sling surgery alone in quality-adjusted life-years (0.87 [95% confidence interval, 0.86-0.89] vs 0.87 [95% confidence interval, 0.86-0.89]; P=.90) or mean reduction in urinary incontinence episodes per day (-4.76 [95% confidence interval, -4.51 to 5.00] vs -4.50 [95% confidence interval, -4.25 to 4.75]; P=.13). When evaluating the overall study population, from both the healthcare sector and societal perspectives, midurethral sling surgery alone was superior to combined treatment. The probability that combined treatment is cost-effective compared with midurethral sling surgery alone is ≤28% from the healthcare sector and ≤19% from the societal perspectives for a willingness-to-pay value of ≤$150,000 per quality-adjusted life-years. For women with baseline Urogenital Distress Inventory irritative scores of ≥50th percentile, combined treatment was cost-effective compared with midurethral sling surgery alone from both the healthcare sector and societal perspectives. The probability that combined treatment is cost-effective compared with midurethral sling surgery alone for this subgroup is ≥90% from both the healthcare sector and societal perspectives, at a willingness-to-pay value of ≥$150,000 per quality-adjusted life-years. CONCLUSION Overall, perioperative behavioral and pelvic floor muscle therapies combined with midurethral sling surgery was not cost-effective compared with midurethral sling surgery alone for the treatment of women with mixed urinary incontinence. However, combined treatment was of good value compared with midurethral sling surgery alone for women with baseline severe urgency urinary incontinence symptoms.
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Affiliation(s)
- Heidi S Harvie
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Vivian W Sung
- Department of Obstetrics and Gynecology, Women and Infants Hospital, the Warren Alpert Medical School of Brown University, Providence, RI
| | - Simon J Neuwahl
- Social, Statistical, and Environmental Sciences, RTI International, Research Triangle Park, NC
| | - Amanda A Honeycutt
- Social, Statistical, and Environmental Sciences, RTI International, Research Triangle Park, NC
| | - Isuzu Meyer
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Shawn Menefee
- Department of Obstetrics and Gynecology, Kaiser Permanente San Diego, San Diego, CA
| | | | - Gena C Dunivan
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, NM
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Sarah J Bass
- Social, Statistical, and Environmental Sciences, RTI International, Research Triangle Park, NC
| | - Marie G Gantz
- Social, Statistical, and Environmental Sciences, RTI International, Research Triangle Park, NC
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Hendrickson WK, Amundsen CL, Rahn DD, Meyer I, Bradley MS, Smith AL, Myers DL, Jelovsek JE, Lukacz ES. Comparison of 100 U With 200 U of Intradetrusor OnabotulinumToxinA for Nonneurogenic Urgency Incontinence. Female Pelvic Med Reconstr Surg 2021; 27:140-146. [PMID: 33620895 PMCID: PMC8117667 DOI: 10.1097/spv.0000000000001020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objective of this study was to compare efficacy and adverse events between 100 U and 200 U of onabotulinumtoxinA for 6 months in women with nonneurogenic urgency incontinence. METHODS This is a secondary analysis of 2 multicenter randomized controlled trials assessing efficacy of onabotulinumtoxinA in women with nonneurogenic urgency incontinence; one compared 100 U to anticholinergics and the other 200 U to sacral neuromodulation. Of 307 women who received onabotulinumtoxinA injections, 118 received 100 U, and 189 received 200 U. The primary outcome was mean adjusted change in daily urgency incontinence episodes from baseline over 6 months, measured on monthly bladder diaries. Secondary outcomes included perceived improvement, quality of life, and adverse events. The primary outcome was assessed via a multivariate linear mixed model. RESULTS Women receiving 200 U had a lower mean reduction in urgency incontinence episodes by 6 months compared with 100 U (-3.65 vs -4.28 episodes per day; mean difference, 0.63 episodes per day [95% confidence interval (CI), 0.05-1.20]). Women receiving 200 U had lower perceptions of improvement (adjusted odds ratio, 0.32 [95% CI, 0.14-0.75]) and smaller improvement in severity score (adjusted mean difference, 12.0 [95% CI, 5.63-18.37]). Upon subanalysis of only women who were treated with prior anticholinergic medications, these differences between onabotulinumtoxinA doses were no longer statistically significant. There was no statistically significant difference in adverse events in women receiving 200 U (catheterization, 32% vs 23%; adjusted odds ratio, 1.4 [95% CI, 0.8-2.4]; urinary tract infection, 37% vs 27%; adjusted odds ratio, 1.5 [95% CI, 0.9-2.6]). CONCLUSIONS A higher dose of onabotulinumtoxinA may not directly result in improved outcomes, but rather baseline disease severity may be a more important prediction of outcomes.
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Affiliation(s)
- Whitney K Hendrickson
- From the Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Cindy L Amundsen
- From the Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - David D Rahn
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, TX
| | - Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Megan S Bradley
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Services, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Ariana L Smith
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Deborah L Myers
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Brown University, Providence, RI
| | - J Eric Jelovsek
- From the Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Emily S Lukacz
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, UC San Diego, San Diego, CA
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11
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Abstract
INTRODUCTION AND HYPOTHESIS The objective was to develop an instructional video that utilizes fluoroscopic images and anatomical landmarks to increase the surgeon's ability to troubleshoot optimal placement of the foramen needle and lead during a stage I sacral neuromodulation (SNM) procedure. METHODS Eight different examples of suboptimal foramen needle placement with subsequent corrections during a SNM procedure were performed and recorded on a fresh female cadaver. RESULTS Fluoroscopic images were obtained during the procedure, and illustrations of the posterior aspect of the sacrum highlighting the S3 foramina and nerve are shown for anatomical comparison. CONCLUSIONS This video demonstrates how to efficiently identify and correct suboptimal foramen needle placement in order to obtain optimal lead placement during an SNM procedure. Understanding the relationship between the bony landmarks on fluoroscopy and the S3 nerve and foramen are important in order to understand how to correct a suboptimal foramen needle and thus achieve optimal lead placement.
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Affiliation(s)
- Whitney K Hendrickson
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, 5324 McFarland Drive, Unit 310, Durham, NC, 27707, USA.
| | - Cindy L Amundsen
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, 5324 McFarland Drive, Unit 310, Durham, NC, 27707, USA
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Flavin R, Pettersson A, Hendrickson WK, Fiorentino M, Finn S, Kunz L, Judson GL, Lis R, Bailey D, Fiore C, Nuttall E, Martin NE, Stack E, Penney KL, Rider JR, Sinnott J, Sweeney C, Sesso HD, Fall K, Giovannucci E, Kantoff P, Stampfer M, Loda M, Mucci LA. SPINK1 protein expression and prostate cancer progression. Clin Cancer Res 2014; 20:4904-11. [PMID: 24687926 DOI: 10.1158/1078-0432.ccr-13-1341] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE SPINK1 overexpression has been described in prostate cancer and is linked with poor prognosis in many cancers. The objective of this study was to characterize the association between SPINK1 overexpression and prostate cancer-specific survival. EXPERIMENTAL DESIGN The study included 879 participants in the U.S. Physicians' Health Study and Health Professionals Follow-Up Study, diagnosed with prostate cancer (1983-2004) and treated by radical prostatectomy. Protein tumor expression of SPINK1 was evaluated by immunohistochemistry on tumor tissue microarrays. RESULTS Seventy-four of 879 (8%) prostate cancer tumors were SPINK1 positive. Immunohistochemical data were available for PTEN, p-Akt, pS6, stathmin, androgen receptor (AR), and ERG (as a measure of the TMPRSS2:ERG translocation). Compared with SPINK1-negative tumors, SPINK1-positive tumors showed higher PTEN and stathmin expression, and lower expression of AR (P < 0.01). SPINK1 overexpression was seen in 47 of 427 (11%) ERG-negative samples and in 19 of 427 (4%) ERG-positive cases (P = 0.0003). We found no significant associations between SPINK1 status and Gleason grade or tumor stage. There was no association between SPINK1 expression and biochemical recurrence (P = 0.56). Moreover, there was no association between SPINK1 expression and prostate cancer mortality (there were 75 lethal cases of prostate cancer during a mean of 13.5 years follow-up; HR = 0.71; 95% confidence interval, 0.29-1.76). CONCLUSIONS Our results suggest that SPINK1 protein expression may not be a predictor of recurrence or lethal prostate cancer amongst men treated by radical prostatectomy. SPINK1 and ERG protein expression do not seem to be entirely mutually exclusive, as some previous studies have suggested.
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Affiliation(s)
- Richard Flavin
- Center for Molecular Oncologic Pathology; Departments of Department of Histopathology, St. James's Hospital and Trinity College Dublin Medical School, Dublin, Ireland
| | - Andreas Pettersson
- Channing Division of Network Medicine, Department of Medicine; Department of Epidemiology, Harvard School of Public Health; and
| | - Whitney K Hendrickson
- Channing Division of Network Medicine, Department of Medicine; Department of Epidemiology, Harvard School of Public Health; and
| | | | - Stephen Finn
- Center for Molecular Oncologic Pathology; Departments of Department of Histopathology, St. James's Hospital and Trinity College Dublin Medical School, Dublin, Ireland
| | - Lauren Kunz
- Channing Division of Network Medicine, Department of Medicine; Department of Epidemiology, Harvard School of Public Health; and
| | - Gregory L Judson
- Channing Division of Network Medicine, Department of Medicine; Department of Epidemiology, Harvard School of Public Health; and
| | - Rosina Lis
- Center for Molecular Oncologic Pathology; Departments of
| | - Dyane Bailey
- Center for Molecular Oncologic Pathology; Departments of
| | | | - Elizabeth Nuttall
- Channing Division of Network Medicine, Department of Medicine; Department of Epidemiology, Harvard School of Public Health; and
| | | | - Edward Stack
- Center for Molecular Oncologic Pathology; Departments of
| | - Kathryn L Penney
- Channing Division of Network Medicine, Department of Medicine; Department of Epidemiology, Harvard School of Public Health; and
| | - Jennifer R Rider
- Channing Division of Network Medicine, Department of Medicine; Department of Epidemiology, Harvard School of Public Health; and
| | - Jennifer Sinnott
- Channing Division of Network Medicine, Department of Medicine; Department of Epidemiology, Harvard School of Public Health; and
| | | | - Howard D Sesso
- Division of Preventive Medicine, Brigham and Women's Hospital
| | - Katja Fall
- Channing Division of Network Medicine, Department of Medicine; Department of Epidemiology, Harvard School of Public Health; and
| | - Edward Giovannucci
- Channing Division of Network Medicine, Department of Medicine; Department of Epidemiology, Harvard School of Public Health; and
| | | | - Meir Stampfer
- Channing Division of Network Medicine, Department of Medicine; Department of Epidemiology, Harvard School of Public Health; and
| | - Massimo Loda
- Center for Molecular Oncologic Pathology; Departments of Medical Oncology and
| | - Lorelei A Mucci
- Channing Division of Network Medicine, Department of Medicine; Department of Epidemiology, Harvard School of Public Health; and
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13
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Kasperzyk JL, Finn SP, Flavin R, Fiorentino M, Lis R, Hendrickson WK, Clinton SK, Sesso HD, Giovannucci EL, Stampfer MJ, Loda M, Mucci LA. Prostate-specific membrane antigen protein expression in tumor tissue and risk of lethal prostate cancer. Cancer Epidemiol Biomarkers Prev 2013; 22:2354-63. [PMID: 24130224 DOI: 10.1158/1055-9965.epi-13-0668] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Overexpression of prostate-specific membrane antigen (PSMA) in tumor tissue and serum has been linked to increased risk of biochemical recurrence in surgically treated prostate cancer patients, but none of the studies have assessed its association with disease-specific mortality. METHODS We examined whether high PSMA protein expression in prostate tumor tissue was associated with lethal disease, and with tumor biomarkers of progression, among participants of two U.S.-based cohorts (n = 902, diagnosed 1983-2004). We used Cox proportional hazards regression to calculate multivariable HRs and 95% confidence intervals (CI) of lethal prostate cancer, defined as disease-specific death or development of distant metastases (n = 95). Partial Spearman rank correlation coefficients were used to correlate PSMA with tumor biomarkers. RESULTS During an average 13 years of follow-up, higher PSMA expression at prostatectomy was significantly associated with lethal prostate cancer (age-adjusted HRQuartile(Q)4vs.Q1 = 2.42; Ptrend < 0.01). This association was attenuated and nonsignificant (multivariable-adjusted HRQ4vs.Q1 = 1.01; Ptrend = 0.52) after further adjusting for Gleason score and prostate-specific antigen (PSA) at diagnosis. High PSMA expression was significantly (P < 0.05) correlated with higher Gleason score and PSA at diagnosis, increased tumor angiogenesis, lower vitamin D receptor and androgen receptor expression, and absence of ets-related gene (ERG) expression. CONCLUSIONS High tumor PSMA expression was not an independent predictor of lethal prostate cancer in the current study. PSMA expression likely captures, in part, malignant features of Gleason grade and tumor angiogenesis. IMPACT PSMA is not a strong candidate biomarker for predicting prostate cancer-specific mortality in surgically treated patients.
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Affiliation(s)
- Julie L Kasperzyk
- Authors' Affiliations: Departments of Epidemiology and Nutrition, Harvard School of Public Health; Channing Division of Network Medicine and Division of Preventive Medicine, Department of Medicine, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School; Center for Molecular Oncologic Pathology, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Histopathology, St. James's Hospital, Dublin, Ireland; Pathology Unit, Addarii Institute of Oncology, Sant' Orsola-Malpighi Hospital, Bologna, Italy; and Division of Medical Oncology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
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Hendrickson WK, Flavin R, Kasperzyk JL, Fiorentino M, Fang F, Lis R, Fiore C, Penney KL, Ma J, Kantoff PW, Stampfer MJ, Loda M, Mucci LA, Giovannucci E. Vitamin D receptor protein expression in tumor tissue and prostate cancer progression. J Clin Oncol 2011; 29:2378-85. [PMID: 21537045 DOI: 10.1200/jco.2010.30.9880] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Data suggest that circulating 25-hydroxyvitamin D [25(OH)D] interacts with the vitamin D receptor (VDR) to decrease proliferation and increase apoptosis for some malignancies, although evidence for prostate cancer is less clear. How VDR expression in tumor tissue may influence prostate cancer progression has not been evaluated in large studies. PATIENTS AND METHODS We examined protein expression of VDR in tumor tissue among 841 patients with prostate cancer in relation to risk of lethal prostate cancer within two prospective cohorts, the Physicians' Health Study and Health Professionals Follow-Up Study. We also examined the association of VDR expression with prediagnostic circulating 25(OH)D and 1,25-dihydroxyvitamin D levels and with two VDR single nucleotide polymorphisms, FokI and BsmI. RESULTS Men whose tumors had high VDR expression had significantly lower prostate-specific antigen (PSA) at diagnosis (P for trend < .001), lower Gleason score (P for trend < .001), and less advanced tumor stage (P for trend < .001) and were more likely to have tumors harboring the TMPRSS2:ERG fusion (P for trend = .009). Compared with the lowest quartile, men whose tumors had the highest VDR expression had significantly reduced risk of lethal prostate cancer (hazard ratio [HR], 0.17; 95% CI, 0.07 to 0.41). This association was only slightly attenuated after adjustment for Gleason score and PSA at diagnosis (HR, 0.33; 95% CI, 0.13 to 0.83) or, additionally, for tumor stage (HR, 0.37; 95% CI, 0.14 to 0.94). Neither prediagnostic plasma vitamin D levels nor VDR polymorphisms were associated with VDR expression. CONCLUSION High VDR expression in prostate tumors is associated with a reduced risk of lethal cancer, suggesting a role of the vitamin D pathway in prostate cancer progression.
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Affiliation(s)
- Whitney K Hendrickson
- Department of Nutrition, Harvard School of Public Health, 655 Huntington Ave, Boston, MA 02115, USA
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