Prostate cancer mortality rates in low- and favorable intermediate-risk active surveillance patients: a population-based competing risks analysis.

PURPOSE: To determine prostate cancer (PCa) and other-cause mortality rates in low- and favorable intermediate-risk (FIR) active surveillance (AS) patients. METHODS: The SEER Prostate with Watchful Waiting database was used to identify men diagnosed with NCCN low or FIR PCa, between 2010 and 2015, managed with AS. FIR patients were subdivided into three subgroups, based on their intermediate risk factor: grade group two (GG2), PSA 10-20 ng/ml or cT2b-c disease. Cumulative incidence function curves with other-cause mortality as the competing risk were utilized. Predictors of PCa mortality were assessed using multivariable regression analysis with semi-parametric proportional hazards modeling. RESULTS: Among 70,871 patients, 48,127 (67.9%) had low and 22,744 (32.1%) had FIR disease. Median patient age was 64.0 years, and median PSA was 5.70 ng/ml. Median follow-up was 49.0 months. There were 166 (0.2%) PCa and 3,176 (4.48%) other-cause mortalities. The 5-year mortality rates in the low and FIR cohorts overall were 0.29% and 0.28%, respectively (p = 0.64). Within the FIR cohort, the corresponding rates were highest in the PSA 10-20 ng/ml subgroup at 0.73%, followed by 0.32% for GG2 FIR and 0.052% for cT2b-c FIR disease (p < 0.001). Older age at diagnosis (sHR 2.38, p = 0.006), Medicaid insurance (sHR: 2.58, p < 0.001), low socioeconomic (sHR 1.39, p = 0.032), and non-married statuses (sHR: 2.58, p < 0.001) were associated with increased PCa mortality. CONCLUSION: Intermediate-term PCa mortality rates in FIR PCa patients are non-significantly different to those with low-risk PCa. However, there is significant within-group heterogeneity, with PCa mortality rates significantly higher in the PSA 10-20 subgroup.

Is there an association between a history of military service and cancer diagnosis? Results from a US national-level study of self-reported outcomes.

PURPOSE: To examine cancer prevalence in men with and without military service history, using national-level self-reported outcomes. METHODS: A cross-sectional survey-based US study, including men aged 18 and above from the Health Information National Trends Survey database between 2011 and 2014. The primary endpoint was self-reported cancer prevalence. Multivariable logistic regression analyses assessed the association of various covariates with the prevalence of cancer. RESULTS: A total of 4,527 men were analyzed, with 1,352 (29.9%) reporting a history of military service. Compared to men with no military service history, men with a military service history were older (median of 65 [IQR 56, 74] vs. 53 [IQR 41, 62] years, p < 0.0001), more commonly Caucasian (71.4% vs. 61.4%, p < 0.0001), born in the US (95.6% vs. 79.5%, p < 0.0001), attained higher education level and annual household income (p < 0.0001), and consisted of more smokers(58.3% vs. 44.5%, p < 0.0001). The age-adjusted comparison demonstrated a higher cancer prevalence in men with military service history (20.5% vs. 7.6%, p < 0.0001). Specifically, genitourinary, dermatological, gastrointestinal, and hematological cancers were generally more prevalent. Adjusting for all available confounders, multivariable models showed that military service history was associated with 1.56 (95% CI 1.20-2.03), and 1.57 (95% CI 1.07-2.31) increased odds of having any cancer, and specifically genitourinary cancer, respectively. CONCLUSIONS: Further research is needed to ascertain whether the association between military service and increased cancer diagnosis results from better screening programs or increased exposure to risk factors during military service.

The association between physician trust and smoking cessation: Implications for motivational interviewing.

Although the relationship between cigarette smoking and increased risk of malignancy has been well established, smoking remains a major public health threat in the United States. Therefore, we examined the relationship between a person's level of trust in cancer information from their physician and the likelihood of quitting smoking in order to better understand the doctor-patient relationship in the context of smoking cessation. The Health Information Nation Trends Survey (2011-2015) was used to identify smokers (n = 2186). Multivariable logistic regression was used to assess the relationship between trust in physicians, the internet, and family members on smoking cessation, accounting for demographic variables. Smokers reported a significantly higher level of trust in cancer information from their physician than cancer information from the internet or family members. However, no significant association between level of trust in cancer information from their physician and wanting to quit smoking was observed (ptrend = 0.55). There was also no association between level of trust in the internet or family and quitting smoking (ptrend = 0.52 and ptrend = 0.83, respectively). These results were confirmed by multivariate analysis. Smoking cessation is not associated with the level of trust an individual has in cancer information from their physician, the internet, or from family members. These findings may impact the utility of standardized information campaigns.

Active surveillance in favorable intermediate-risk prostate cancer patients: Predictors of deferred intervention and treatment choice.

INTRODUCTION: Active surveillance (AS) is increasingly used for favorable intermediate-risk (FIR) prostate cancer (PCa). Our objective was to determine oncological and sociodemographic predictors of deferred definitive therapy and decision for radical prostatectomy (RP) vs. radiotherapy (RT). METHODS: The Surveillance, Epidemiology, and End Results (SEER) Prostate with Watchful Waiting database was used to identify all FIR PCa diagnosed between 2010 and 2015 opting for AS for at least one year following diagnosis. We sought to determine predictors of treatment and treatment type using multivariable logistic regression. RESULTS: A total of 20 334 patients were identified. An annual decrease in incident FIR patients managed initially with AS between 2010 (4061) and 2015 (2947) was noted (p for trend &lt;0.001); 17 895 (88.0%) patients underwent deferred RP and/or RT. Patients with higher baseline cancer volume and clinical stage were significantly more likely to discontinue AS. Patients of higher socioeconomic status were more likely to undergo deferred therapy, with increased odds for RT over RP. African American patients had lower odds of undergoing definitive intervention (odds ratio 0.83, p=0.030) and were significantly more likely to opt for XRT. Oncological characteristics leading to FIR classification influenced treatment choice at the time of deferred intervention: RT was treatment of choice in 86.3% and 86.0% of Gleason group 2 and prostate-specific antigen 10-20 FIR patients, respectively; 96.1% of treated cT2b-c FIR patients opted for RP. CONCLUSIONS: Most FIR PCa patients initially managed with AS eventually undergo deferred definitive therapy, with choice of treatment significantly influenced by patients' baseline oncological and sociodemographic characteristics.

First Case of a Term Male Born with Aphallia and Complete Urethral Atresia.

Aphallia is an exceedingly rare condition often associated with an array of genitourinary anomalies. Classically, aphallia was thought to have to co-exist with a urethral fistula for adequate urine outflow to avoid the sequelae of oligohydramnios, while the absence of a fistula has historically been incompatible with life. We report the first case of a prenatally unrecognized aphallia with complete urethral atresia in a full-term baby, without an associated fistula or ectopic urethra. We postulate a urachal cyst noted on prenatal ultrasound resolved into a patent urachus providing sufficient outflow to avoid sequelae of oligohydramnios and allowed for term birth.

Pathologic upgrading in favorable intermediate risk active surveillance patients: Clinical heterogeneity and implications for active surveillance decision.

INTRODUCTION: Current guidelines support active surveillance (AS) for select patients with favorable intermediate risk (FIR) prostate cancer (CaP). A significant proportion of FIR CaP patients undergoing surgical treatment are found to have evidence of adverse pathology. Our objective was to determine the incidence and predictors of pathologic upgrading in FIR AS patients undergoing radical prostatectomy. MATERIALS AND METHODS: The Surveillance, Epidemiology, and End Results Prostate with Watchful Waiting (WW) database was used to identify men younger than 80 years with National Comprehensive Cancer Network FIR CaP initially opting for AS and/or WW between 2010 and 2015 and subsequently underwent radical prostatectomy at least one year following diagnosis. Patients were assigned into one of three subgroups based on their intermediate risk factor: Gleason Score 7(3 + 4) (Group 1), prostate specific antigen level of 10-20 ng/ml (Group 2), and cT2b-c (Group 3). Pathologic upgrading was present in Group 1 if pathologic GS was 7 (4 + 3) or worse. For patients in Groups 2 and 3, upgrading occurred if pathologic GS was 7 (3 + 4) or worse. Oncologic and sociodemographic predictors of pathologic upgrading were evaluated univariable and multivariable logistic regression analysis. RESULTS: 18,760 patients were identified. Pathologic upgrading occurred in 138 (13.3%), 59 (25.0%), and 8,011 (45.8%) patients in groups 1, 2, and 3 respectively. Pathologic downgrading occurred in 226 (21.7%) patients in group 1. Significant predictors of pathologic upgrading on multivariable analysis included older age at diagnosis: 70 to 79 vs. 40 to 49 years (Groups 1 and 3, P < 0.05), a more recent diagnosis: 2014 to2015 vs. 2010-2011 (Groups 2 and 3, P < 0.005), higher volume disease: 37.5% to 49.9% vs. 0% to 12.4% (Groups 2 and 3, P < 0.005), and clinically palpable disease (Groups 1 and 2, P < 0.05). Additional risk factors for upgrading included uninsured or Medicaid status, diagnosis in a Western region (Group 2), African American ethnicity and higher socioeconomic status (Group 3) CONCLUSIONS: FIR CaP is a clinically heterogeneous risk group with incidence of pathologic upgrading ranging from 13.3% in those with GS 7 (3 + 4) to 45.8% in those with cT2b-c disease. Risk of pathologic upgrading in FIR CaP patients initially managed with AS and/or WW is significantly associated with multiple patient-level oncologic and sociodemographic variables.

Influence of Sociodemographic Factors on Definitive Intervention Among Low-risk Active Surveillance Patients.

OBJECTIVES: To investigate sociodemographic factors influencing decision of initially active surveillance (AS) prostate cancer (CaP) patients to opt for definitive therapy, and, specifically, choice of radical prostatectomy (RP) versus radiation therapy (XRT). METHODS: The Surveillance, Epidemiology, and End Results (SEER) Prostate with Watchful Waiting database was used to identify AS patients diagnosed with NCCN low-risk CaP between 2010 and 2015. We sought to determine predictors of treatment type using multivariable logistic regression analyses. RESULTS: Out of 32,874 men included, 21,255 (64.7%) underwent delayed treatment, with 3,751 (17.6%) and 17,463 (82.2%) opting for RP and XRT, respectively. Patients who were married (Odds Ratio [OR]: 1.18, P <.001), insured (OR 2.94, P <.001), of higher socioeconomic status (OR 1.67 for highest vs lowest, P <.01), and residing in a Southeastern or Midwestern region (ORs 1.26 and 1.22 vs Northeast, respectively, P <.01) were significantly more likely to undergo definitive intervention. A significant interaction between patient race and marital/socioeconomic statuses on the decision-making process was identified. Decision for XRT (vs RP) was more likely in older (OR 11.6 for 70-79 vs 50-59 years, P <.01), unmarried (OR 1.89, P <.01), African American (OR 1.41, P .018), and higher socioeconomic status (OR 1.54 for highest versus lowest quartile, P <.01) patients. CONCLUSION: The majority of patients initially treated with AS underwent delayed treatment. After accounting for pathologic characteristics, the interaction of sociodemographic factors including race, socioeconomic status, marital status, insurance status, and region of residence are significantly associated with the likelihood of undergoing definitive therapy.

Upgrading on radical prostatectomy specimens of very low- and low-risk prostate cancer patients on active surveillance: A population-level analysis.

INTRODUCTION: A proportion of prostate cancer (PCa) patients initially managed with active surveillance (AS) are upgraded to a higher Gleason score (GS) at the time of radical prostatectomy (RP). Our objective was to determine predictors of upgrading on RP specimens using a national database. METHODS: The Surveillance, Epidemiology, and End Results Prostate with Watchful Waiting database was used to identify AS patients diagnosed with very low- or low-risk PCa who underwent delayed RP between 2010 and 2015. The primary outcome was upgrading to GS 7 disease or worse. Logistic regression analyses were used to evaluate demographic and oncological predictors of upgrading on final specimen. RESULTS: A total of 3775 men underwent RP after a period of AS, 3541 (93.8%) of whom were cT2a; 792 (21.0%) patients were upgraded on RP specimen, with 85.4%, 10.6%, and 3.4% upgraded to GS 7(3+4), 7(4+3), and 8 diseases, respectively. On multivariable analysis, higher prostate-specific antigen (PSA) at diagnosis (5-10 vs. 0-2 ng/ml, odd ratio [OR] 2.59, p<0.001) and percent core involvement (80-100% vs. 0-20%, OR 2.52, p=0.003) were significant predictors of upgrading on final RP specimen, whereas higher socioeconomic status predicted lower odds of upgrading (highest vs. lowest quartile OR 0.75, p=0.013). CONCLUSIONS: Higher baseline PSA and percent positive cores involvement are associated with significantly increased risk of upgrading on RP after AS, whereas higher socioeconomic status predicts lower odds of such events. These results may help identify patients at increased risk of adverse pathology on final specimen who may benefit from earlier definitive treatment.