Race, demographics, and socioeconomics as they relate to newly diagnosed metastatic prostate cancer in the United States

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Background: As screening practices evolve, understanding the influence race, demographics, and socioeconomic status have on the presentation of metastatic prostate cancer (mPCa) can lead to improved diagnostic strategies in high-risk populations. Methods: Men diagnosed with prostate cancer in the National Cancer Data Base from 2004-2013 were identified. Characteristics of men presenting with and without metastatic disease were compared. A four-level composite metric of SES was created using census-based income and education data. Multivariable logistic regression analysis evaluated the association of age, SES, race/ethnicity, insurance status and other relevant covariates with the likelihood of presenting with mPCa. Results: Of the 1,034,754 PCa patients identified, 4% presented with mPCa. Compared to the highest SES group, odds of mPCa increased continuously with decreasing SES. A total of 24% of White men were in the lowest SES while more than half of Black and Hispanic men were in lowest SES category. Black and Hispanic men had higher overall rates of metastases (5.9% and 6.2%; OR 1.47, 95% CI 1.43-1.51 and OR 1.22, 95% CI 1.17-1.28, respectively) compared to Whites (3.6%). Having Medicaid or no insurance increased the odds of being diagnosed with mPCa compared to having other insurance (13% vs 4%; OR 3.91, 95% 3.78-4.05) with all other variables held constant, including SES. Among men in the lowest SES, the effect of SES appeared to be additive to race: OR 1.34 (95% CI 1.29-1.39), OR 2.09 (95% CI 2.00-1.78), and OR 1.66 (95% CI 1.56-1.77), for White, Black, and Hispanic ethnicity all in the lowest SES group, respectively. Across each race, men aged 75 and older had the highest rates of mPCa. Overall, Black men over age 74 had a higher rate of mPCa (14%) relative to Whites (9%) and Hispanics (11%). Conclusions: There is an inverse relationship between SES and odds of presenting with mPCa. Having no insurance or Medicaid increased the odds of mPCa, even when accounting for SES. Black and Hispanic race was associated with increased odds of mPCa, and the effects of race and SES appeared to be additive.

Temporal trends and factors associated with overuse of neoadjuvant androgen deprivation therapy in low and very low risk prostate cancer

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Background: Evidence has emerged that androgen deprivation (ADT) use prior to radical prostatectomy or radiation therapy in low risk prostate cancer patients does not provide a survival benefit and may subject patients to adverse side effects and clinical outcomes. We examined trends and factors associated with ADT use prior to definitive therapy in low and very low risk prostate cancer. Methods: We identified men diagnosed with low or very low risk prostate cancer in the National Cancer Database from 2004-2013 who elected definitive treatment with radical prostatectomy (RP), external beam radiation (EBRT) or brachytherapy (BT). Neoadjuvant ADT use was defined as receipt of ADT prior to definitive treatment. Trends in neoadjuvant ADT use were assessed and multivariable logistic regression was used to evaluate associations between treatment, age, race, insurance status and urban/rural status and receipt of neoadjuvant ADT. Results: Of 199,933 patients with low or very low risk prostate cancer, neoadjuvant ADT use decreased from 14.6% in 2004 to 2.7% in 2013 (23.0% to 8.8% for BT, 20.6% to 6.0% for EBRT and 2.3% to 0.5% for RP; each p for trend < 0.001). Controlling for covariates and year, we found increased odds [OR (95% CI)] of neoadjuvant ADT use in patients undergoing BT [12.01 (11.23-12.83)] or EBRT [8.75 (8.16-9.39)], African Americans [1.08 (1.02-1.14)] vs. whites, patients 75 or older [1.93 (1.80-2.06)] and 65-74 [1.52 (1.44-1.60)] vs. less than 65, patients in communities less than 250,000 [1.28 (1.23-1.34)] vs. metropolitan areas and patients with Medicare or Medicaid [1.22 (1.16-1.29)] vs. private insurance. Conclusions: Use of ADT prior to definitive prostate cancer treatment has declined over the past decade. However, patients receiving radiotherapy, African Americans, patients of older age, rural location, and insured by Medicare or Medicaid more frequently received neoadjuvant ADT. Since this treatment is unlikely to provide a survival benefit and may subject patients to adverse side effects or clinical outcomes, strategies to minimize overuse of ADT in low or very low risk patients prior to definitive therapy may help limit overtreatment and its associated harms.

Risk of non-melanoma cancers in first-degree relatives of CDKN2A mutation carriers

The purpose of this study was to quantify the risk of cancers other than melanoma among family members of CDKN2A mutation carriers using data from the Genes, Environment and Melanoma study. Relative risks (RRs) of all non-melanoma cancers among first-degree relatives (FDRs) of melanoma patients with CDKN2A mutations (n = 65) and FDRs of melanoma patients without mutations (n = 3537) were calculated as the ratio of estimated event rates (number of cancers/total person-years) in FDRs of carriers vs noncarriers with exact Clopper-Pearson-type tests and 95% confidence intervals (CIs). All statistical tests were two-sided. There were 56 (13.1%) non-melanoma cancers reported among 429 FDRs of mutation carriers and 2199 (9.4%) non-melanoma cancers in 23 452 FDRs of noncarriers. The FDRs of carriers had an increased risk of any cancer other than melanoma (56 cancers among 429 FDRs of carrier probands vs 2199 cancers among 23 452 FDRs of noncarrier probands; RR = 1.5, 95% CI = 1.2 to 2.0, P = .005), gastrointestinal cancer (20 cancers among 429 FDRs of carrier probands vs 506 cancers among 23 452 FDRs of noncarrier probands; RR = 2.4, 95% CI = 1.4 to 3.7, P = .001), and pancreatic cancer (five cancers among 429 FDRs of carrier probands vs 41 cancers among 23 452 FDRs of noncarrier probands; RR = 7.4, 95% CI = 2.3 to 18.7, P = .002). Wilms tumor was reported in two FDRs of carrier probands and three FDRs of noncarrier probands (RR = 40.4, 95% CI = 3.4 to 352.7, P = .005). The lifetime risk of any cancer other than melanoma among CDKN2A mutation carriers was estimated as 59.0% by age 85 years (95% CI = 39.0% to 75.4%) by the kin-cohort method, under the standard assumptions of Mendelian genetics on the genotype distribution of FDRs conditional on proband genotype.

Racial differences in the structure and function of the stress urinary continence mechanism

OBJECTIVE

To compare the structure and function of the urethral sphincter and the urethral support in nulliparous black and white women.

METHODS

Eighteen black women (mean age 28.1 years) and 17 white women (mean age 31.3 years) completed this cross-sectional study. The following assessments were made: urethral function using multichannel cystometrics and urethral pressure profilometry, pelvic muscle strength using an instrumented speculum, urethral mobility using the cotton-swab test and perineal ultrasound, and pelvic muscle bulk using magnetic resonance imaging.

RESULTS

Black women demonstrated a 29% higher average urethral closure pressure during a maximum pelvic muscle contraction (154 cm H(2)O versus 119 cm H(2)O in the white subjects; P =.008). Although not statistically significant, black women had a 14% higher maximum urethral closure pressure at rest (108 cm H(2)O versus 95 cm H(2)O; P =.23) and a 21% larger urethral volume (4818 mm(3) versus 3977 mm(3); P =.06). In addition, there was a 36% greater vesical neck mobility measured with the cotton-swab test (blacks 49 degrees versus whites 36 degrees; P =.02) and a 42% difference in ultrasonically measured vesical neck mobility during a maximum Valsalva effort (blacks = -17 mm versus whites -12 mm; P =.08).

CONCLUSION

Functional and morphologic differences exist in the urethral sphincteric and support system of nulliparous black and white women.

Differential effects of cough, valsalva, and continence status on vesical neck movement

OBJECTIVE

We tested the null hypothesis that vesical neck descent is the same during a cough and during a Valsalva maneuver. We also tested the secondary null hypothesis that differences in vesical neck mobility would be independent of parity and continence status.

METHODS

Three groups were included: 17 nulliparous continent (31.3 +/- 5.6; range 22-42 years), 18 primiparous continent (30.4 +/- 4.3; 24-43), and 23 primiparous stress-incontinent (31.9 +/- 3.9; 25-38) women. Measures of vesical neck position at rest and during displacement were obtained by ultrasound. Abdominal pressures were recorded simultaneously using an intravaginal microtransducer catheter. To control for differing abdominal pressures, the stiffness of the vesical neck support was calculated by dividing the pressure exerted during a particular effort by the urethral descent during that effort.

RESULTS

The primiparous stress-incontinent women displayed similar vesical neck mobility during a cough effort and during a Valsalva maneuver (13.8 mm compared with 14.8 mm; P =.49). The nulliparous continent women (8.2 mm compared with 12.4 mm; P =. 001) and the primiparous continent women (9.9 mm compared with 14.5 mm; P =.002) displayed less mobility during a cough than during a Valsalva maneuver despite greater abdominal pressure during cough. The nulliparas displayed greater pelvic floor stiffness during a cough compared with the continent and incontinent primiparas (22.7, 15.5, 12.2 cm H(2)O/mm, respectively; P =.001).

CONCLUSION

There are quantifiable differences in vesical neck mobility during a cough and Valsalva maneuver in continent women. This difference is lost in the primiparous stress-incontinent women.

Sonographic evaluation of the bladder neck in continent and stress-incontinent women

OBJECTIVE

To evaluate a new sonographic method to measure depth and width of proximal urethral dilation during coughing and Valsalva maneuver and to report its use in a group of stress-incontinent and continent women.

METHODS

Fifty-eight women were evaluated, 30 with and 28 without stress incontinence proven urodynamically, with a bladder volume of 300 mL and the subjects upright. Urethral pressure profiles at rest were performed with a 10 French microtip pressure catheter. Bladder neck dilation and descent were assessed by perineal ultrasound (5 MHz curved linear array transducer) with the help of ultrasound contrast medium (galactose suspension-Echovist-300), whereas abdominal pressure was assessed with an intrarectal balloon catheter. Statistical analysis used the nonparametric Mann-Whitney test.

RESULTS

The depth and diameter of urethral dilation could be measured in all women. During Valsalva, all 30 incontinent women exhibited urethral dilation. One incontinent woman showed dilation only while performing a Valsalva maneuver, not during coughing. In the continent group, 12 women presented dilation during Valsalva and six during coughing. In continent women, dilation was visible only in those who were parous. Nulliparous women did not have dilation during Valsalva or coughing. Bladder neck descent was visible in continent and incontinent women.

CONCLUSION

This method permits quantification of depth and diameter of bladder neck dilation, showing that both incontinent and continent women might have bladder neck dilation and that urinary continence can be established at different locations along the urethra in different women. Parity seems to be a main prerequisite for a proximal urethral defect with bladder neck dilation.

Quantification of cough-related urine loss using the paper towel test

OBJECTIVE

To develop and test a simple and rapid method for quantifying the urine loss resulting from three deep coughs using an ordinary brown paper towel.

METHODS

A brown paper towel is held lightly against the perineum during three single coughs performed in the upright stance. The resulting wetted area was calculated using simple geometry; if desired, leakage volume can be interpolated from a calibration curve, which demonstrates the relationship between wetted area (cm2) and volume (mL) of leakage. Four bench tests of the method were performed. In addition, the test-retest reliability of the method was evaluated in eight elderly women with mild stress urinary incontinence, a sample size adequate to detect a 1-mL difference with 80% power.

RESULTS

The smallest measurable quantity of fluid resulted in a wetted area of 0.04 cm2 (equivalent to 0.2 microl). For leakage volumes up to 6 mL, the regression showed that each 1 mL of fluid volume resulted in an average 25.4 cm2 increase in wetted area (coefficient of determination: 0.97). In eight women with stress incontinence 95% of within- and across-visit comparisons of urine loss were within 1 mL.

CONCLUSION

The paper towel test is a simple and reliable measure providing immediate visual and quantitative feedback of cough-related urine loss typical of mild-to-moderate stress urinary incontinence.

Effect of pelvic muscle exercise on transient incontinence during pregnancy and after birth

OBJECTIVE

To test the effect of pelvic muscle exercise on postpartum symptoms of stress urinary incontinence and pelvic muscle strength in primigravidas during pregnancy and postpartum.

METHODS

A prospective trial randomized women into treatment (standardized instruction in pelvic muscle exercise) or control (routine care with no systematic pelvic muscle exercise instruction). Urinary incontinence symptoms were measured by questionnaire. Pelvic muscle strength was quantified by an instrumented gynecologic speculum. Time points were 20 and 35 weeks' gestation and 6 weeks, 6 months, and 12 months postpartum.

RESULTS

Outcomes are reported for 46 women with vaginal or cesarean birth and for a subsample of 37 women with vaginal birth. Longitudinal analyses are reported for cases with complete data across time points. Diminished urinary incontinence symptoms were seen in the treatment group, with significant treatment effects demonstrated at 35 weeks' gestation (F [1,43] = 4.36, P = .043), 6 weeks postpartum (F [1,43] = 4.94, P = .032), and 6 months postpartum (F [1,43] = 4.29, P = .044). A repeated measures analysis of variance showed a significant interaction between time and treatment for urinary incontinence (F [4, 41] = 2.83, P = .037). A significant effect of initial pelvic muscle strength was demonstrated; ie, pelvic muscle strength at 20 weeks' gestation predicted significantly 12-months postpartum strength (F [1, 13] = 8.12, P = .014). Group differences in pelvic muscle strength were observed (the treatment group had greater strength at 6 weeks and at 6 months postpartum than did controls), but these differences were not statistically significant.

CONCLUSION

Practice of pelvic muscle exercise by primiparas results in fewer urinary incontinence symptoms during late pregnancy and postpartum.

Size of the urogenital hiatus in the levator ani muscles in normal women and women with pelvic organ prolapse

OBJECTIVE

Compare urogenital hiatus size in normal women and women with pelvic organ prolapse.

METHODS

The sagittal and transverse urogenital hiatus diameters were measured and hiatus area calculated in 300 women whose support was scored using a modified Baden system.

RESULTS

In women with normal support and without prior surgery, hiatus area was 5.4 cm2 (+/-1.71 standard deviation [SD], n = 197). In women with uncorrected clinical prolapse (grade 2-3), the area of the hiatus was enlarged (9.6 cm2 +/- 3.97, n = 34, P < .05) and became larger with progressive prolapse (grade 0, 5.4 cm2 +/- 1.71, n = 197; grade 1, 7.3 cm2 +/- 1.91, n = 27; grade 2, 8.3 cm2 +/- 2.45, n = 18; grade 3, 11.0 cm2 +/- 4.90, n = 16). When matched for age and parity, prolapse patients had a larger hiatus than normal women. Women with recurrent prolapse had a larger hiatus than cured women (13.3 cm2 +/- 3.86, n = 8 compared with 8.1 cm2 +/- 2.44, n = 16, P < .05) or women with recurrence after one operation (8.9 cm2 +/- 1.77, n = 18, P < .05). Hiatus size in patients surgically cured (8.3 cm2 +/- 2.44, n = 16) did not return to normal (5.4 cm2 +/- 1.71, n = 197, P < .05). Increasing area of the hiatus was correlated with an increase in anterior-posterior diameter (r2 = 0.9, P < .05), was less attributable to increased transverse diameter (r2 = 0.6, P < .05), and was not related to thickness of the perineal body (r2 = 0.0, P > .05).

CONCLUSION

Increasing pelvic organ prolapse is associated with increasing urogenital hiatus size; the hiatus is larger after several failed operations than after successful surgery or single failure.

Intraurethral ultrasound correlated with urethral histology

OBJECTIVE

To examine the anatomic identity of sonographically visible sphincteric structures of the female urethra.

METHODS

The urethra, urinary bladder, and vagina were removed from 11 fresh female cadavers and placed in a water bath. Intraurethral ultrasound was performed with a 360 degrees-rotating 7.5-MHz ultrasound probe. Afterward, the specimens were fixed and cross sections were made transverse to the urethral axis at 5-mm intervals. Corresponding ultrasonograms and histologic images were matched and depicted simultaneously side by side. The anatomic identity of sonographically visible structures was determined by histologic examination and thickness of the longitudinal smooth urethral sphincter measured.

RESULTS

Structures visible sonographically were the striated and smooth urethral sphincter muscle layers, vagina, and blood vessels with diameters exceeding 0.2 mm. The longitudinal smooth muscle layer appeared as a well-defined internal hypoechoic ring. The outer circular smooth muscle layers and the striated muscle layers were a more irregular and hyperechoic zone. The circular smooth muscle layers and the striated sphincter muscle layers could not always be differentiated easily. With formalin fixation, tissue shrinkage resulted in a smaller thickness of the longitudinal smooth muscle measured on the histologic specimen.

CONCLUSION

With intraurethral ultrasound, the longitudinal smooth muscle layer appears as a well-defined and measurable hypoechoic ring. The region of the circular smooth muscle and the striated muscle emerges as a hyperechoic and less definable outer zone.

Internal and external anal sphincter anatomy as it relates to midline obstetric lacerations

OBJECTIVE

To examine the anatomy of the internal and external anal sphincters in the area of midline obstetric lacerations, to gain insight into sphincter damage and repair.

METHODS

The length, craniocaudal extent, and overlap of the internal and external anal sphincters in the perineal body were measured in 17 cadavers. Further anatomic observations were made in four sets of whole pelvis cross-sections taken in the sagittal, coronal, and transverse planes. During the repair of 20 acute fourth-degree lacerations, observations were made to determine the internal sphincter visibility following birth.

RESULTS

The external and internal and sphincters overlap by 17.0 mm (standard deviation [SD] 6.9), with the internal sphincter lying between the external sphincter and the anal canal. The internal sphincter extends an additional 12.2 mm (SD 5.9) cranial to the proximal extent of the external sphincter, whereas the caudal margin of the internal sphincter lies 3.7 mm (SD 7.2) cranial to the distal margin of the external sphincter. In pregnant women who sustained a fourth-degree laceration, we found that the internal sphincter can be identified as a rubbery white layer adjacent to the anal submucosa lying between the external sphincter and the anal canal.

CONCLUSION

The internal anal sphincter lies between the anal mucosa and the external anal sphincter and extends more than a centimeter above the cranial margin of the external sphincter, a region where it is disrupted when a fourth-degree obstetric laceration has occurred.

Pelvic organ prolapse in young women

OBJECTIVE

To determine differences in the characteristics and type of genital prolapse in young women compared with older women.

METHODS

A retrospective analysis was performed, identifying 647 women who underwent surgical repair of various types of genital prolapse for the years 1979-1991. One hundred ninety-one patients met our inclusion criteria, having well-documented genital prolapse to or beyond the hymen. Patients were stratified into two age groups, those over 35 years and those 35 or younger. The patients were compared regarding "complexity" of prolapse (ie, the total number of deficient sites per patient), grade of prolapse, parity and coexistent medical conditions.

RESULTS

During the study period, 27 young women (mean age +/- standard deviation [SD] 30.3 +/- 3.4 years) and 164 older women (mean age +/- SD 60.6 +/- 11.9 years) met our criteria. Young women were more likely than older women to have 1) potential predisposing medical conditions (congenital anomalies or neurologic or connective tissue diseases) (22.2% versus 6.7%, P < .05), 2) lower mean parity (2.8 versus 3.4, P < .05), 3) only one site of prolapse (56% versus 23%, P < .01), and 4) lower grade of prolapse (33% versus 87% grade 3 or higher, P < .001).

CONCLUSION

Young patients undergoing surgery for genital prolapse were more likely to have lower parity and single-site and lower-grade prolapse. A higher than expected prevalence of congenital anomalies, as well as rheumatologic and neurologic diseases in the younger women is intriguing, but further study is necessary before these conditions can be implicated in the genesis of genital prolapse.

Changes in vesical neck mobility following vaginal delivery

OBJECTIVE

To assess changes in urethral movement during the Valsalva maneuver and pelvic floor muscle contraction following vaginal delivery.

METHODS

In a prospective repeated-measures study, 25 primigravidas, 20 multiparas, and ten women who were to have elective cesarean delivery were examined sonographically at 36-42 weeks of pregnancy and 6-10 weeks after delivery. Vesical neck position at rest and excursion during Valsalva maneuver and maximum pelvic muscle contraction were measured with perineal ultrasound. Data about resting bladder neck position and bladder neck elevation at contraction were compared with findings in age-matched nulligravid volunteers.

RESULTS

The bladder neck was significantly lower at rest in women after vaginal delivery than in those who had an elective cesarean delivery and in nulligravid controls. Bladder neck mobility had increased during the Valsalva maneuver in 16 of 25 primigravidas and 15 of 20 multiparas 6-10 weeks after vaginal delivery. The ability to elevate the vesical neck during pelvic muscle contraction was decreased in six of 25 primigravidas and in two of 20 multiparas 6-10 weeks after birth. Two women, one primigravid and one para 2 (with a previous elective cesarean delivery), both of whom had forceps delivery, completely lost the ability to contract voluntarily the pelvic floor muscles.

CONCLUSION

Vaginal delivery alters vesical neck descent during the Valsalva maneuver, and the ability of the pelvic muscles to elevate the urethra in some women.

Magnetic resonance imaging anatomy of the female urethra: a direct histologic comparison

OBJECTIVE

To define the urethral structures visible on magnetic resonance imaging (MRI) relevant to stress urinary incontinence.

METHODS

The urethra and surrounding tissues were harvested from 13 female cadavers (ages 21-81) and fixed in 10% buffered formalin. High-resolution T1- and T2-weighted images were obtained at 1.5 tesla. Mallory trichrome-stained histologic sections were prepared in corresponding planes from the cadaveric specimens. Immunohistologic stains for smooth muscle (actin) and vascular endothelium (CD-34 and factor VIII) were obtained on two specimens. Histology and MRI were compared using side-by-side correlation of projected images and by superimposing projected images. Comparison was also made to a non-cadaveric urethral MRI of a 29-year-old woman and to the MRI of another specimen imaged pre- and post-fixation.

RESULTS

Distinct layers of the cadaveric urethra were seen best on proton density and T2-weighted images. From the center to the periphery, a series of concentric rings were visible: an inner bright ring, the mucosa; a dark ring, the submucosa; an outer bright ring, the smooth muscle of the urethra in a loose connective tissue matrix; and a peripheral dark ring, the striated urogenital sphincter muscle of the urethra in dense connective tissue. No significant alterations were caused by fixation. These cadaveric images matched the non-cadaveric MRI of the 29-year-old woman.

CONCLUSION

The internal urethral anatomy visible on high-resolution MRI can be identified and confirmed histologically, and these findings may form the basis for future anatomic investigation of stress urinary incontinence and other urethral abnormalities.