Perioperative outcomes and hospital reimbursement by type of radical prostatectomy: results from a privately insured patient population

BACKGROUND

With the increasing use of robotic surgery in the United States, the comparative effectiveness and differences in reimbursement of minimally invasive radical prostatectomy (MIRP) and open prostatectomy (ORP) in privately insured patients are unknown. Therefore, we sought to assess the differences in perioperative outcomes and hospital reimbursement in a privately insured patient population who were surgically treated for prostate cancer.

METHODS

Using a large private insurance database, we identified 17,610 prostate cancer patients who underwent either MIRP or ORP from 2003 to 2010. The primary outcomes were length of stay (LOS), perioperative complications, 90-day readmissions rates and hospital reimbursement. Multivariable regression analyses were used to evaluate for differences in primary outcomes across surgical approaches.

RESULTS

Overall, 8981 (51.0%) and 8629 (49.0%) surgically treated prostate cancer patients underwent MIRP and ORP, respectively. The proportion of patients undergoing MIRP markedly rose from 11.9% in 2003 to 72.5% in 2010 (P<0.001 for trend). Relative to ORP, MIRP was associated with a shorter median LOS (1.0 day vs 3.0 days; P<0.001) and lower adjusted odds ratio of perioperative complications (OR: 0.82; P<0.001). However, the 90-day readmission rates of MIRP and ORP were similar (OR: 0.99; P=0.76). MIRP provided higher adjusted mean hospital reimbursement compared with ORP (US $19,292 vs. US $17,347; P<0.001).

CONCLUSIONS

Among privately insured patients diagnosed with prostate cancer, robotic surgery rapidly disseminated with over 70% of patients undergoing MIRP by 2009-2010. Although MIRP was associated with shorter LOS and modestly better perioperative outcomes, hospitals received higher reimbursement for MIRP compared with ORP.

Piperlongumine promotes autophagy via inhibition of Akt/mTOR signalling and mediates cancer cell death

BACKGROUND

The Akt/mammalian target of rapamycin (mTOR) signalling pathway serves as a critical regulator of cellular growth, proliferation and survival. Akt aberrant activation has been implicated in carcinogenesis and anticancer therapy resistance. Piperlongumine (PL), a natural alkaloid present in the fruit of the Long pepper, is known to exhibit notable anticancer effects. Here we investigate the impact of PL on Akt/mTOR signalling.

METHODS

We examined Akt/mTOR signalling in cancer cells of various origins including prostate, kidney and breast after PL treatment. Furthermore, cell viability after concomitant treatment with PL and the autophagy inhibitor, Chloroquine (CQ) was assessed. We then examined the efficacy of in vivo combination treatment using a mouse xenograft tumour model.

RESULTS

We demonstrate for the first time that PL effectively inhibits phosphorylation of Akt target proteins in all tested cells. Furthermore, the downregulation of Akt downstream signalling resulted in decrease of mTORC1 activity and autophagy stimulation. Using the autophagy inhibitor, CQ, the level of PL-induced cellular death was significantly increased. Moreover, concomitant treatment with PL and CQ demonstrated notable antitumour effect in a xenograft mouse model.

CONCLUSIONS

Our data provide novel therapeutic opportunities to mediate cancer cellular death using PL. As such, PL may afford a novel paradigm for both prevention and treatment of malignancy.

Evaluating prostate cancer mortality and competing risks of death in patients with localized prostate cancer using a comprehensive nomogram

BACKGROUND

The aim of this study was to determine the optimal treatment for a patient with newly diagnosed prostate cancer weighing the individual's risk of disease progression against his risk of non-cancer death.

METHODS

We developed a predictive model incorporating clinicopathological tumor variables, patient age, comorbidity status, and primary treatment modality. We identified 6091 patients with clinically-localized prostate cancer managed with radical prostatectomy (n=4117) or radiation therapy (n=1974) from the Cancer of the Prostate Strategic Urologic Research Endeavor database. Fine and Gray competing-risks proportional hazards regression models were used to calculate the risks of prostate cancer-specific mortality (PCSM) and non-prostate cancer death and to generate a nomogram.

RESULTS

The median follow-up after treatment was 53 months (interquartile range 30, 80 months). In total, 983 men died during follow-up, including 167 who died of prostate cancer and 816 who died of non-prostate cancer causes. On multivariate analysis, higher Cancer of the Prostate Risk Assessment score and primary treatment with radiation were associated with an increased risk of PCSM, whereas older age, African-American race, and treatment with radiation predicted non-prostate cancer death. The number of comorbidities and receipt of androgen deprivation therapy correlated with an increased risk of non-prostate cancer death, but not PCSM. The resulting nomogram allows quantification and comparison of the 10-year risk of PCSM and non-prostate cancer death.

CONCLUSIONS

Integrating clinicopathological variables with comorbid conditions in a competing-risks model affords quantification and comparison of relative probabilities of PCSM and non-prostate cancer death following treatment. Our model thereby facilitates an individualized approach for counseling patients regarding prostate cancer management.

A novel web-based tool for risk quantification and objectification of treatment of renal cell carcinoma

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Background: Despite the development of treatment guidelines, the management of renal cell carcinoma (RCC) remains overly subjective. Nomograms and statistical algorithms promise more objective decision making by patients and physicians by quantifying risk. Unfortunately, these tools remain underutilized in daily clinical practice because they are both cumbersome and time-consuming. We sought to create a novel website where all the available and relevant nomograms for RCC could be easily accessible for patients and practitioners, minimizing the subjectivity associated with clinical risk stratification and decision-making.

Methods: The existing literature was reviewed to identify published nomograms relevant to RCC. Nomograms were grouped by defining characteristics (preoperative versus postoperative predictive models, predictive models for metastatic disease, etc). Additional operationalized models included staging tools, surveillance models and cancer statistics. Nomograms were selected based on predictive accuracy, applicability, and ability to objectify risk stratification. Only nomograms with an AUC of greater than 0.7 were operationalized. The times required to extract clinical metrics for four hypothetical clinical scenarios were compared between the original paper version and our web-based model.

Results: www.cancernomograms.com organizes and operationalizes interactive predictive models for RCC for both physicians and patients. Each model was developed as an independent software program and deployed as an interactive flash object embedded in an HTML page allowing point of care risk calculation. In an initial sample of 15 subjects, the website decreased nomogram metric output from minutes to seconds, proving that utilization of a computer-based platform for these nomograms is faster (p=0.0003).

Conclusions: www.cancernomograms.com is a novel website that allows point of care risk quantification and objectified decision making using published statistical models. This web tool may help improve physician and patient communication and clinical care.

No significant financial relationships to disclose.

Synchronous metastatic renal cell carcinoma to the genitourinary tract: two rare case reports and a review of the literature

Synchronous metastasis of renal cell carcinoma (RCC) to the ureter or the bladder represents an extremely rare event. We report one case of synchronous metastasis of RCC to the ipsilateral ureter and one case of solitary synchronous metastasis of RCC to the urinary bladder. We review the literature and discuss possible mechanisms of dissemination. We discuss the surgical management of metastases from RCC as well as the surgical options in the treatment of these rare occurrences.