Trans Oblique Ileal Conduit Technique Has a Low Risk of Parastomal Hernias.

OBJECTIVE: To outline our surgical technique and outcomes of a ipsilateral "transoblique" ileal conduit performed during pelvic exenteration with a Vertical Rectus Abdominis Myocutaneous flap. We report hernia rates in a transrectus group as reference. METHODS: We identified patients from January 2007 to August 2020. The transoblique conduit is placed on the ipsilateral side as the VRAM, through the internal, external oblique, and transverse abdominis muscles. Stomal hernias were assessed radiologically. Transrectus patients were those undergoing radical cystectomy matched based on surgery date, age, and sex in a 3:1 ratio. We employed a Kaplan-Meier plot to visualize the duration between surgery and hernia. We calculated the hernia rate 2 years after surgery. Additionally, we present the 30-day postoperative complication rate. RESULTS: Fifty underwent transoblique conduits and we matched them to 190 transrectus patients. Sixty-seven percent were men with a median age of 62. Exactly 10/50 patients in the transoblique and 44/190 in the transrectus group developed a hernia, with a median follow-up of 2.2 years (IQR 0.8, 4.0). The 2-year KM-estimated parastomal hernia rate was 14% (95% CI 1.6%, 25%) for the transoblique conduits, 21% (95% CI 15%, 28%) for the transrectus and 24% (95% CI 6.5%, 39%) for colostomies. Among the transoblique patients, 22 (44%) experienced at least 1 postoperative complication. CONCLUSION: A transoblique ileal conduit is safe in patients undergoing a right VRAM flap during a pelvic exenteration with a low parastomal hernia and complication rates.

A Novel Frailty Index Can Predict the Short-Term Outcomes of Esophagectomy in Older Patients with Esophageal Cancer.

Background: Frailty, rather than age, is associated with postoperative morbidity and mortality. We sought to determine whether preoperative frailty as defined by a novel scoring system could predict the outcomes among older patients undergoing esophagectomy. Methods: We identified patients 65 years or older who underwent esophagectomy between 2011 and 2021 at our institution. Frailty was assessed using the MSK-FI, which consists of 1 component related to functional status and 10 medical comorbidities. We used a multivariable logistic regression model to test for the associations between frailty and short-term outcomes, with continuous frailty score as the predictor and additionally adjusted for age and Eastern Cooperative Oncology Group performance status. Results: In total, 447 patients were included in the analysis (median age of 71 years [interquartile range, 68-75]). Most of the patients underwent neoadjuvant treatment (81%), an Ivor Lewis esophagectomy (86%), and minimally invasive surgery (55%). A total of 22 patients (4.9%) died within 90 days of surgery, 144 (32%) had a major complication, 81 (19%) were readmitted, and 31 (7.2%) were discharged to a facility. Of the patients who died within 90 days, 19 had a major complication, yielding a failure-to-rescue rate of 13%. The risk of 30-day major complications (OR, 1.24 [95% CI, 1.09-1.41]; p = 0.001), readmissions (OR, 1.31 [95% CI, 1.13-1.52]; p < 0.001), and discharge to a facility (OR, 1.86 [95% CI, 1.49-2.37]; p < 0.001) increased with increasing frailty. Frailty and 90-day mortality were not associated. Conclusions: Frailty assessment during surgery decision-making can identify patients with a high risk of morbidity.

Association between objective measures of oral health and salivary gland irradiation with patient-reported outcomes following head and neck radiation therapy.

PURPOSE: To determine whether objective measures of oral health and salivary gland irradiation correlates with subjective measures of eating, drinking, and salivation in patients following head and neck radiation therapy (HNRT). METHODS: This cross-sectional study included 112 patients following HNRT with a completed patient-reported outcome (PRO) scale. Objective measures at post-HNRT visit included decayed-missing-filled teeth (DMFT) scores, periodontal disease condition, oral hygiene status, dental prosthesis use, and prescribed radiation dose to salivary glands. Data were collected and statistical analysis was performed. RESULTS: There was no significant association between PRO scales and dental prosthesis use, periodontal disease, and oral hygiene. Although some significant findings were seen with DMFT and prescribed radiation dose to salivary glands, this explained only very small amounts of the variation in eating, drinking, and salivation measures in these patients. CONCLUSION: PRO measures should be integrated in the routine care of patients with head and neck cancer.

Electronic Patient-Reported Symptoms After Ambulatory Cancer Surgery.

Importance: Complex cancer procedures are now performed in the ambulatory surgery setting. Remote symptom monitoring (RSM) with electronic patient-reported outcomes (ePROs) can identify patients at risk for acute hospital encounters. Defining normal recovery is needed to set patient expectations and optimize clinical team responses to manage evolving problems in real time. Objective: To describe the patterns of postoperative recovery among patients undergoing ambulatory cancer surgery with RSM using an ePRO platform-the Recovery Tracker. Design, Setting, and Participants: In this retrospective cohort study, patients who underwent 1 of 5 of the most common procedures (prostatectomy, nephrectomy, mastectomy, hysterectomy, or thyroidectomy) at the Josie Robertson Surgery Center at Memorial Sloan Kettering Cancer Center from September 2016 to June 2022. Patients completed the Recovery Tracker, a brief ePRO platform assessing symptoms for 10 days after surgery. Data were analyzed from September 2022 to May 2023. Main Outcomes and Measures: Symptom severity and interference were estimated by postoperative day and procedure. Results: A total of 12 433 patients were assigned 110 936 surveys. Of these patients, 7874 (63%) were female, and the median (IQR) age at surgery was 57 (47-65) years. The survey response rate was 87% (10 814 patients responding to at least 1 of 10 daily surveys). Among patients who submitted at least 1 survey, the median (IQR) number of surveys submitted was 7 (4-8), and each assessment took a median (IQR) of 1.7 (1.2-2.5) minutes to complete. Symptom burden was modest in this population, with the highest severity on postoperative days 1 to 3. Pain was moderate initially and steadily improved. Fatigue was reported by 6120 patients (57%) but was rarely severe. Maximum pain and fatigue responses (very severe) were reported by 324 of 10 814 patients (3%) and 106 of 10 814 patients (1%), respectively. The maximum pain severity (severe or very severe) was highest after nephrectomy (92 of 332 [28%]), followed by mastectomy with reconstruction (817 of 3322 [25%]) and prostatectomy (744 of 3543 [21%]). Nausea (occasionally, frequently, or almost constantly) was common and experienced on multiple days by 1485 of 9300 patients (16%), but vomiting was less common (139 of 10 812 [1%]). Temperature higher than 38 °C was reported by 740 of 10 812 (7%). Severe or very severe shortness of breath was reported by 125 of 10 813 (1%). Conclusions and Relevance: Defining detailed postoperative symptom burden through this analysis provides valuable data to inform further implementation and maintenance of RSM programs in surgical oncology patients. These data can enhance patient education, set expectations, and support research to allow iterative improvement of clinical care based on the patient-reported experience after discharge.

Cognitive function and ability to complete a web-based geriatric assessment among older adults with cancer.

BACKGROUND: The purpose of this study was determined whether cognitive impairment is associated with time taken to complete the electronic rapid fitness assessment (eRFA). We hypothesized that taking more time to complete the eRFA will indicate worsened cognitive function. METHODS: We retrospectively identified patients who presented to the Memorial Sloan Kettering Cancer Center Geriatrics Service for preoperative evaluation and completed the eRFA as a part of their preoperative assessment from February 2015 to December 2020. Cognitive function was assessed using the Mini-Cog©, which is a screening test for cognitive function status. Patients in this study underwent elective surgery and had a hospital length of stay ≥1 day. Time to complete the eRFA was automatically recorded by a web-based tool; assistance with eRFA completion was self-reported by the patient. In total, 2599 patients were included, of which 2387 had available Mini-Cog© scores. RESULTS: Overall, 50% of surveys were completed without assistance, 37% were completed with assistance, and 13% were completed by somebody else; Mini-Cog© scores were lower, corresponding to worsened cognitive function status, in patients requiring assistance (median score respectively, 5 vs. 4 vs. 3; p-value <0.0001; rates of cognitive impairment 7.5%, 22%, and 38%). Among patients who completed the questionnaire independently, greater cognitive impairment was associated with longer time to complete the eRFA (change in score per 5 min = -0.09; 95% CI -0.14, -0.03; p = 0.002). CONCLUSIONS: We found evidence that requirement for assistance in completing web-based questionnaires, and time taken to complete a questionnaire, predict which patients benefit from more comprehensive cognitive function assessments. Future studies should further validate this finding in a more diverse population and establish optimal clinical pathways.

Comparison of salvage radical prostatectomy vs. salvage ablation therapy for biopsy-proven radio-recurrent localized prostate cancer.

INTRODUCTION: Radiation therapy for prostate cancer is associated with a 15-20% five-year recurrence rate. Patients with recurrence in the prostate only are candidates for salvage local therapies; however, there is no consensus on modality. This study uses registries at Memorial Sloan Kettering Cancer Center (MSKCC) and University of Western Ontario (UWO) to compare the oncologic outcomes of salvage radical prostatectomy (SRP) and salvage ablation (SA). METHODS: A total of 444 patients were available for analysis. Due to intergroup differences, propensity score methodology was used and identified 378 patients with more comparable pre-salvage prostate-specific antigen (PSA), Gleason score, and primary radiation treatment. Patients underwent SRP at MSKCC and SA at UWO. RESULTS: Of the 378 patients, 48 died of disease, with a 6.0-year median (interquartile range [IQR] 3.0, 9.7) followup among survivors; 88 developed metastases, with a median 4.6-year (IQR 2.3, 7.9) followup among metastasis-free survivors. There was a non-significantly higher rate of cancer-specific (hazard ratio [HR ] 1.02, 95% confidence interval [CI] 0.51, 2.06, p=0.9) and improved metastasis-free survival (HR 0.71, 95% CI 0.44, 1.13, p=0.15) among patients undergoing SA compared to patients undergoing SRP. There were 143 patients who received hormonal therapy, with higher rates of androgen deprivation therapy (ADT) in SA (HR 1.42, 95% CI 0.97, 2.08, p=0.068), although this did not meet conventional levels of significance. CONCLUSIONS: This propensity score analysis of salvage therapy for radio-recurrent prostate cancer identified no statistically significant differences in oncologic outcome between SRP and SA; however, there was evidence of a lower risk of ADT in the cohort undergoing SRP. Given they are both potentially curative therapies, these treatments are viable options for men with clinically localized, radio-recurrent prostate cancer rather than ADT alone. Future research may further elucidate subpopulations that may be more amenable to either SRP or SA.

Preoperative frailty predicts postoperative falls in older patients with cancer.

INTRODUCTION: Patient falls in the hospital lead to adverse outcomes and impaired quality of life. Older adults with cancer who are frail may be at heightened risk of falls in the postoperative period. We sought to evaluate the association between degree of preoperative frailty and risk of inpatient postoperative falls and other outcomes among older adults with cancer. MATERIALS AND METHODS: We identified 7,661 patients aged 65 years or older who underwent elective cancer surgery from 2014 to 2020, had a hospital stay of ≥1 day, and had Memorial Sloan Kettering-Frailty Index (MSK-FI) data to allow assessment of frailty. Univariable logistic regression analysis was performed to evaluate the association between frailty and falls. Multivariable logistic regression analysis was performed to evaluate the composite outcome of 30-day readmission or 90-day death, with frailty, falls, and the interaction between frailty and falls as predictors; the analysis was adjusted for age, sex, race, and preoperative albumin level. RESULTS: In total, 7,661 patients were included in the analysis. Seventy-one (0.9%) had a fall, of whom eight (11%) were readmitted to the hospital within 30 days and seven (10%) died within 90 days. Higher MSK-FI score was associated with higher risk of falls (odds ratio [OR], 1.40 [95% confidence interval [CI], 1.21-1.59]). The risk of falls for a patient with an MSK-FI score of 1 was 0.6%, compared with 1.7% for a patient with an MSK-FI score of 4. Poor outcome was associated with frailty (OR, 1.07 [95% CI, 1.02-1.13]) but not with falls (OR, 1.17 [95% CI, 0.57-2.22]). DISCUSSION: Preoperative frailty is associated with risk of inpatient postoperative falls and with other adverse outcomes after surgery among older adults with cancer. Screening for frailty in the preoperative setting would enable healthcare institutions to implement interventions aimed at reducing the incidence of inpatient postoperative falls to reduce fall-related adverse events.

Pain as bad as you can imagine or extremely severe pain? A randomized controlled trial comparing two pain scale anchors.

BACKGROUND: A common method of pain assessment is the numerical rating scale, where patients are asked to rate their pain on a scale from 0 to 10, where 0 is "no pain" and 10 is "pain as bad as you can imagine". We hypothesize such language is suboptimal as it involves a test of a cognitive skill, imagination, in the assessment of symptom severity. METHODS: We used a large-scale online research registry, ResearchMatch, to conduct a randomized controlled trial to compare the distributions of pain scores of two different pain scale anchors. We recruited adults located in the United States who reported a chronic pain problem (> 3 months) and were currently in pain. Participants were randomized in a 1:1 ratio to receive pain assessment based on a modified Brief Pain Inventory (BPI), where the anchor for a score of 10 was either "extremely severe pain", or the original BPI, with the anchor "pain as bad as you can imagine". Participants in both groups also answered additional questions about pain, other symptomatology and creativity. RESULTS: Data were obtained from 405 participants for the modified and 424 for the original BPI. Distribution of responses to pain questions were similar between groups (all p-values ≥ 0.12). We did not see evidence that the relationship between pain score and the anchor text differed based on self-perceived creativity (all interaction p-values ≥ 0.2). However, in the key analysis, correlations between current pain assessments and known correlates (fatigue, anxiety, depression, current pain compared to a typical day, pain compared to other people) were stronger for "extreme" vs. "imaginable" anchor text (p = 0.005). CONCLUSION: Pain rating scales should utilize the modified anchor text "extremely severe pain" instead of "pain as bad as you can imagine". Further research should explore the effects of anchors for other symptoms.

Differential use of postoperative psychosocial and physical services among older adults with head and neck cancer.

INTRODUCTION: Older adults undergoing head and neck cancer (HNC) surgery often have significant functional and mental health impairments. We examined use of postoperative physical, nutritional, and psychosocial services among a cohort of older adults with HNC comanaged by geriatricians and surgeons. MATERIALS AND METHODS: Our sample consisted of older adults who were referred to the Geriatrics Service at Memorial Sloan Kettering Cancer Center between 2015 and 2019 and took a geriatric assessment (GA) prior to undergoing HNC surgery. Physical, nutritional, and psychosocial service utilization was assessed. Physical services included a physical, occupational, or rehabilitation consult during the patient's stay. Nutritional services consisted of speech and swallow or nutritional consult. Psychosocial services consisted of psychiatry, psychology, or a social work consult. Relationships between each service use, geriatric deficits, demographic, and surgical characteristics were assessed using Wilcoxon rank-sum test or Chi-square test. RESULTS: In total, 157 patients were included, with median age of 80 and length of stay of six days. The most common GA impairments were major distress (61%), depression (59%), social activity limitation (SAL) (54%), and deficits in activities of daily living (ADL) (44%). Nutritional and physical services were used much more frequently than psychosocial services (80% and 85% vs 31%, respectively). Receipt of services was associated with longer median length of hospital stay, operation time, and greater deficits in ADLs. SAL was associated with physical and psychosocial consult and lower Timed Up and Go (TUG) score; instrumental ADL (iADL) deficits were associated with physical services; and depression and distress were associated with psychosocial services. DISCUSSION: The burden of psychosocial deficits is high among older adults with HNC. Future work is needed to understand the limited utilization of psychosocial services in this population as well as whether referral to psychosocial services can reduce the burden of these deficits.

The Highest Grade Group Does Not Drive the Risk of Recurrence when Systematic and Multiparametric Magnetic Resonance Imaging (MRI)-targeted Biopsies are Discordant: Preliminary Findings Using Radical Prostatectomy Pathology as a Surrogate for MRI-targeted Biopsy Grade.

Pathology grading of prostate biopsy follows the rule that the highest International Society of Urological Pathology grade group (GG) is the GG assigned. This rule was developed in the systematic biopsy (SBx) era and makes sense when samples are from very different areas of the prostate. This rule has been kept for multiparametric magnetic resonance imaging (mpMRI)-targeted biopsy (MRI-TBx), for which multiple samples-targeted and systematic-are taken from small areas. In particular, if the results for SBx and MRI-TBx are discordant, the patient is assigned the higher GG. However, the most appropriate grading when MRI-TBx and SBx grades are discordant has never been investigated empirically. A cohort of patients who have undergone SBx and MRI-TBx with long oncological follow-up does not yet exist. To estimate the risk of recurrence for every combination of biopsy and pathological grades, we used the GG on radical prostatectomy (RP) as a surrogate for GG on MRI-TBx GG surrogate. We analyzed data for 12 468 men who underwent SBx and RP at a tertiary referral center and assessed 5-yr biochemical recurrence-free survival (bRFS) for each pairwise combination of biopsy and surgical GG results. We found that for cases with discordant SBx and RP grades, the risk of recurrence was intermediate, irrespective of whether the highest grade was at RP or SBx. For instance, the 5-yr bRFS rate was 57% for men with GG 3 on RP and 60% for men with GG 3 on SBx, but 63% for men with RP GG 3 and SBx GG 2, and 79% for men with RP GG 2 and SBx GG 3. Translating these findings to MRI-TBx casts doubt on current grading practice: when GGs are discordant between SBx and MRI-TBx, the risk of biochemical recurrence risk is not driven by the highest grade but by an intermediate between the two grades. Our findings should motivate studies assessing long-term outcomes for patients undergoing both MRI-TBx and SBx with a view to empirically evaluating current grading practices. PATIENT SUMMARY: Patients with prostate cancer may undergo two biopsy types: (1) systematic biopsy, for which sampling follows a systematic template; and (2) targeted biopsy, for which samples are taken from lesions detected on scans. There may be a difference in prostate cancer grade identified by the two approaches. In such cases, the risk of cancer recurrence seems to be predicted by an intermediate grade between the lower and higher grades.

The oncologic risk of magnetic resonance imaging-targeted and systematic cores in patients treated with radical prostatectomy.

BACKGROUND: Magnetic resonance imaging (MRI)-targeted prostate biopsy (MRI-biopsy) detects high-Grade Group (GG) prostate cancers not identified by systematic biopsy (S-biopsy). However, questions have been raised whether cancers detected by MRI-biopsy and S-biopsy, grade-for-grade, are of equivalent oncologic risk. The authors evaluated the relative oncologic risk of GG diagnosed by S-biopsy and MRI-biopsy. METHODS: This was a retrospective analysis of all patients who had both MRI-biopsy and S-biopsy and underwent with prostatectomy (2014-2022) at Memorial Sloan Kettering Cancer Center. Three logistic regression models were used with adverse pathology as the primary outcome (primary pattern 4, any pattern 5, seminal vesicle invasion, or lymph node involvement). The first model included the presurgery prostate-specific antigen level, the number of positive and negative S-biopsy cores, S-biopsy GG, and MRI-biopsy GG. The second model excluded MRI-biopsy GG to obtain the average risk based on S-biopsy GG. The third model excluded S-biopsy GG to obtain the risk based on MRI-biopsy GG. A secondary analysis using Cox regression evaluated the 12-month risk of biochemical recurrence. RESULTS: In total, 991 patients were identified, including 359 (36%) who had adverse pathology. MRI-biopsy GG influenced oncologic risk compared with S-biopsy GG alone (p < .001). However, if grade was discordant between biopsies, then the risk was intermediate between grades. For example, the average risk of advanced pathology for patients who had GG2 and GG3 on S-biopsy was 19% and 66%, respectively, but the average risk was 47% for patients who had GG2 on S-biopsy and patients who had GG3 on MRI-biopsy. The equivalent estimates for 12-month biochemical recurrence were 5.8%, 15%, and 10%, respectively. CONCLUSIONS: The current findings cast doubt on the practice of defining risk group based on the highest GG. Because treatment algorithms depend fundamentally on GG, further research is urgently required to assess the oncologic risk of prostate tumors depending on detection technique. PLAIN LANGUAGE SUMMARY: Using magnetic resonance imaging (MRI) to help diagnose prostate cancer can help identify more high-grade cancers than using a systematic template biopsy alone. However, we do not know if high-grade cancers diagnosed with the help of an MRI are as dangerous to the patient as high-grade cancers diagnosed with a systematic biopsy. We examined all of our patients who had an MRI biopsy and a systematic biopsy and then had their prostates removed to find out if these patients had risk factors and signs of aggressive cancer (cancer that spread outside the prostate or was very high grade). We found that, if there was a difference in grade between the systematic biopsy and the MRI-targeted biopsy, the risk of aggressive cancer was between the two grades.

Implementation of 4Kscore as a Secondary Test Before Prostate Biopsy: Impact on US Population Trends for Prostate Cancer.

Prostate cancer screening using prostate-specific antigen (PSA) reduces prostate cancer mortality at the cost of unnecessary prostate biopsy, overdiagnosis, and overtreatment. Several secondary tests have been developed to restrict biopsy to men at the greatest risk of high-grade disease. 4Kscore is a widely used secondary test that has been shown to reduce biopsy rates by approximately two-thirds in routine clinical practice. We estimated how 4Kscore implementation has affected cancer trends in the US population. We combined data from the US validation study of 4Kscore with data from the diagnostic test impact study, using a basis of 70 000 on-label 4Kscore tests performed annually. We estimate that each year, 4Kscore leads to 45 200 fewer biopsies and 9400 fewer overdiagnoses of low-grade cancer, at the cost of delayed diagnosis of high-grade prostate cancer for 3450 patients, of whom two-thirds have International Society of Urological Pathology grade group 2 disease. These findings need to be taken into consideration when studying epidemiologic trends in prostate cancer. They also suggest that high levels of overdiagnosis and overtreatment are not inevitable characteristics of PSA screening, but can be mitigated by additional tests. Patient summary: We estimate that use of a test called 4Kscore to predict the probability that a patient has high-grade prostate cancer has significantly reduced the number of unnecessary biopsies and overdiagnosis of low-grade cancer in the USA. These decisions may result in delayed diagnosis of high-grade cancer in some patients. 4Kscore is a useful additional test in the management of prostate cancer.

Assessment of Patients With Prostate Cancer and Their Understanding of the International Prostate Symptom Score Questionnaire.

Purpose: The International Prostate Symptom Score (IPSS) is a widely used tool for evaluating patient-reported lower urinary tract symptoms. In this study, we assessed patients with prostate cancer and their understanding of IPSS questions. Methods and Materials: Consecutive patients with prostate cancer (N = 144) self-completed an online IPSS questionnaire within 1 week before their visit at our radiation oncology clinic. At the visit, a nurse reviewed each IPSS question to ensure the patient understood it and then verified the patient's answer. Preverified and nurse-verified scores were recorded and analyzed for discrepancies. Results: Complete concordance between preverified and nurse-verified responses to individual IPSS questions existed for 70 men (49%). In terms of overall IPSS score, 61 men (42%) had a lower or improved IPSS after nurse verification, and 9 men (6%) had a higher or worse IPSS. Before verification, patients overstated their symptoms of frequency, intermittency, and incomplete emptying. As a result of the nurse verification, 4 of 7 patients with IPSS in the severe range (20-35) were recategorized to the moderate range (8-19). Sixteen percent of patients whose preverified IPSS were in the moderate range were recategorized after nurse verification to the mild range (0-7). Treatment option eligibility changed for 10% of patients after nurse verification. Conclusions: Patients frequently misunderstand the IPSS questionnaire, leading them to respond in ways that do not accurately reflect their symptoms. Clinicians should verify patient understanding of the IPSS questions, particularly when using the score to determine eligibility for treatments.

Predictive value of kallikrein forms and ß-microseminoprotein in blood from patients with evidence of detectable levels of PSA after radical prostatectomy.

PURPOSE: To determine whether ß-microseminoprotein or any of the kallikrein forms in blood-free, total or intact PSA or total hK2-predict metastasis in patients with evidence of detectable levels of PSA in blood after radical prostatectomy. METHOD: We determined marker concentrations in blood from 173 men treated with radical prostatectomy and evidence of detectable levels of PSA in the blood (PSA ≥ 0.05) after surgery between 2014 and 2015 and at least 1 year after any adjuvant therapy. We used Cox regression to determine whether any marker was associated with metastasis using both univariate and multivariable models that included standard clinical predictors. RESULTS: Overall, 42 patients had metastasis, with a median follow-up of 67 months among patients without an event. The levels of intact and free PSA and free-to-total PSA ratio were significantly associated with metastasis. Discrimination was highest for free PSA (c-index: 0.645) and free-to-total PSA ratio (0.625). Only free-to-total PSA ratio remained associated with overall metastasis (either regional or distant) after including standard clinical predictors (p = 0.025) and increased discrimination from 0.686 to 0.697. Similar results were found using distant metastasis as an outcome (p = 0.011; c-index increased from 0.658 to 0.723). CONCLUSION: Our results provide evidence that free-to-total PSA ratio can risk stratifying patients with evidence of detectable levels of PSA in blood after RP. Further research is warranted on the biology of prostate cancer markers in patients with evidence of detectable levels of PSA in blood after radical prostatectomy. Our findings on the free-to-total ratio for predicting adverse oncologic outcomes need to be validated in other cohorts.

Preoperative glucose in surgical oncology patient is not associated with postoperative outcomes after adjustment for frailty.

BACKGROUND: Observational studies have shown associations between even small elevations in preoperative glucose and poorer outcomes, including increased length of stay (LOS) and higher mortality. This has led to calls for aggressive glycemic control in the preoperative period, including delay of treatment until glucose is reduced. However, it is not known whether there is a direct causal effect of blood glucose or whether adverse outcomes result from overall poorer health in patients with higher glucose. METHODS: Analysis was performed using a retrospective database of patients aged 65 and older who underwent cancer surgery. The last measured preoperative glucose was the exposure variable. The primary outcome was extended LOS (>4 days). Secondary outcomes included mortality, acute kidney injury (AKI), major postoperative complications during the admission period, and readmission within 30 days. The primary analysis was a logistic regression with prespecified covariates: age, sex, surgical service, and the Memorial Sloan Kettering-Frailty Index. In an exploratory analysis, lasso regression was used to select covariates from a list of 4160 candidate variables. RESULTS: This study included 3796 patients with a median preoperative glucose of 104 mg/dL (interquartile range: 93-125). Higher preoperative glucose was univariately associated with increased odds of LOS > 4 days (odds ratio [OR]: 1.45, 95% confidence interval [CI]: 1.22-1.73), with similar results for AKI, readmission, and mortality. Adjustment for confounders eliminated these associations for LOS (OR: 0.97 [95% CI: 0.80-1.18]) and attenuated all other glucose-outcome associations. Lasso regression gave comparable results to the primary analysis. Using the upper bound of the respective 95% confidence interval, we estimated that, at best, successful reduction of elevated preoperative glucose would reduce the risk of LOS > 4 days, 30-day major complication, and 30-day mortality by 4%, 0.5%, and 1.3%, respectively. CONCLUSIONS: Poor outcomes following cancer surgery in older adults with elevated glucose are most likely related to poorer overall health in these patients rather than a direct causal effect of glucose. Aggressive glycemic management in the preoperative period has very limited potential benefits and is therefore unwarranted.

The effect of the da Vinci® Vessel Sealer on robot-assisted laparoscopic prostatectomy complications.

The da Vinci® Vessel Sealer is a major contributor to the total cost of robot-assisted laparoscopic prostatectomy (RALP). We aimed to assess whether the use of the Vessel Sealer is associated with better surgical outcomes in a population of patients that underwent RALP with lymphadenectomy. We tested whether the use of the Vessel Sealer is associated with the development of lymphocele and/or other surgical outcomes. Most surgeons used the Vessel Sealer in almost all or almost no patients. Thus, to avoid the potential confounding variable of surgeon skill, we performed the initial analyses using data from a single surgeon who changed practice over time, and then using the entire population. Overall, the Vessel Sealer was used in 500 (36%) RALPs. Surgeon 1 performed 492 surgeries, and used the Vessel Sealer in 191 (39%). The Vessel Sealer was not associated with better surgical outcomes in patients operated on by Surgeon 1. The odds ratio for development of lymphocele was 1.95 (95% confidence interval [CI] 0.57-6.75). In the entire population, use of the sealer was significantly associated with a very small reduction of blood loss (22 cc, CI 13-30) but with a 32-min increase in the operating room time (CI 26-37). Use of the Vessel Sealer will have, at best, a very small effect on RALP outcomes that is of highly questionable relevance given its cost. In light of these results, the Vessel Sealer will only be used at our institution in the context of clinical trials.

Preoperative frailty vs. cognitive impairment: Which one matters most for postoperative delirium among older adults with cancer?

INTRODUCTION: Limited data are available to explore the association between preoperative frailty and cognitive impairment with postoperative delirium among older adults with cancer. We explored this association in a single Comprehensive Cancer Center where postoperative delirium and frailty are assessed in routine care using the Confusion Assessment Method (CAM) and Memorial Sloan Kettering Frailty Index (MSK-FI), respectively. MATERIALS AND METHODS: Retrospective study on patients with cancer, aged 65+, who underwent surgery from April 2018 to March 2019 with hospital stay ≥1 day. We used logistic regression with postoperative delirium as the outcome, primary predictor MSK-FI, adjusted for age, operative time, and preoperative albumin. As the MSK-FI includes a component related to cognitive impairment, we additionally evaluated the impact of this component, separately from the rest of the score, on the association between frailty and postoperative delirium. RESULTS: Among 1,257 patients with available MSK-FI and CAM measures, 47 patients (3.7%) had postoperative delirium. Increased frailty was associated with increased risk of postoperative delirium (odds ratio [OR] 1.51; 95% confidence interval [CI] 1.26, 1.81; p < 0.001). However, this was largely related to the effect of cognitive impairment (OR 15.29; 95% CI 7.18; 32.56; p < 0.001). In patients with cognitive impairment, the association between frailty and postoperative delirium was not significant (OR 0.97; 95% CI 0.65, 1.44; p-value = 0.9), as having cognitive impairment put patients at high risk for postoperative delirium even without taking into account the other components of the MSK-FI. While the association between frailty and postoperative delirium in patients with intact cognitive function was statistically significant (OR 1.58; 95% CI 1.27, 1.96; p < 0.001), it was not clinically meaningful, particularly considering the low risk of delirium among patients with intact cognitive function (e.g., 1.3% vs 3.2% for MSK-FI 1 vs 3). DISCUSSION: Cognitive function should be a greater focus than frailty, as measured by the MSK-FI, in preoperative assessment for the prediction of postoperative delirium.

Development and implementation of an interdisciplinary telemedicine clinic for older patients with cancer-Preliminary data.

BACKGROUND: Frailty assessment is an important marker of the older adult's fitness for cancer treatment independent of age. Pretreatment geriatric assessment (GA) is associated with improved mortality and morbidity outcomes but must occur in a time sensitive manner to be useful for cancer treatment decision making. Unfortunately, time, resources and other constraints make GA difficult to perform in busy oncology clinics. We developed the Cancer and Aging Interdisciplinary Team (CAIT) clinic model to provide timely GA and treatment recommendations independent of patient's physical location. METHODS: The interdisciplinary CAIT clinic model was developed utilizing the surge in telemedicine during the COVID-19 pandemic. The core team consists of the patient's oncologist, geriatrician, registered nurse, pharmacist, and registered dietitian. The clinic's format is flexible, and the various assessments can be asynchronous. Patients choose the service method-in person, remotely, or hybrid. Based on GA outcomes, the geriatrician provides recommendations and arrange interventions. An assessment summary including life expectancy estimates and chemotoxicity risk calculator scores is conveyed to and discussed with the treating oncologist. Physician and patient satisfaction were assessed. RESULTS: Between May 2021 and June 2022, 50 patients from multiple physical locations were evaluated in the CAIT clinic. Sixty-eight percent was 80 years of age or older (range 67-99). All the evaluations were hybrid. The median days between receiving a referral and having the appointment was 8. GA detected multiple unidentified impairments. About half of the patients (52%) went on to receive chemotherapy (24% standard dose, 28% with dose modifications). The rest received radiation (20%), immune (12%) or hormonal (4%) therapies, 2% underwent surgery, 2% chose alternative medicine, 8% were placed under observation, and 6% enrolled in hospice care. Feedback was extremely positive. CONCLUSIONS: The successful development of the CAIT clinic model provides strong support for the potential dissemination across services and institutions.