Active Surveillance for Intermediate Risk Prostate Cancer: Survival Outcomes in the Sunnybrook Experience.

PURPOSE: To assess the applicability of active surveillance in patients with intermediate risk prostate cancer, we compared the survival outcomes of patients with low risk and intermediate risk disease. MATERIALS AND METHODS: Active surveillance was offered to all patients with low risk (cT1-T2b and Gleason score 6 and prostate specific antigen 10 ng/ml or less) and select intermediate risk disease (age greater than 70 years with cT2c or prostate specific antigen 15 ng/ml or less, or Gleason score 3+4 or less). Data from November 1995 to May 2013 were extracted from a prospectively collected database. The primary outcome was metastasis-free survival, and secondary outcomes were overall survival, cause specific survival and treatment-free survival. RESULTS: A total of 213 intermediate risk and 732 low risk cases were identified. Median age was 72 years (IQR 67.3, 76.8) in the intermediate risk cohort and 67 years (IQR 60.6, 71.9) in the low risk group. Median followup was comparable (6.7 years for intermediate risk vs 6.5 years for low risk). Gleason 7 disease comprised 60% of the intermediate risk cohort. The 15-year metastasis-free, overall, cause specific and treatment-free survival rates were inferior in the intermediate risk group (metastasis-free survival HR 3.14, 95% CI 1.51-6.53, p=0.001, 82% for intermediate risk vs 95% for low risk). On further evaluation the estimated 15-year metastasis-free survival for cases of Gleason 6 or less with prostate specific antigen less than 10 ng/ml was 94%, Gleason 6 or less with prostate specific antigen 10 to 20 ng/ml was 94%, Gleason 3+4 with prostate specific antigen 20 ng/ml or less was 84% and Gleason 4+3 with prostate specific antigen 20 ng/ml or less was 63%. CONCLUSIONS: These data support the use of active surveillance in low risk and intermediate risk cases of Gleason 6 but not Gleason 7 prostate cancer. Multiparametric magnetic resonance imaging and novel biomarkers might be vital in detecting favorable Gleason 7 disease.

Gleason Upgrading with Time in a Large Prostate Cancer Active Surveillance Cohort.

PURPOSE: We report the percentage of patients on active surveillance who had disease pathologically upgraded and factors that predict for upgrading on surveillance biopsies. MATERIALS AND METHODS: Patients in our active surveillance database with at least 1 repeat prostate biopsy were included. Histological upgrading was defined as any increase in primary or secondary Gleason grade on repeat biopsy. Multivariate analysis was used to determine baseline and dynamic factors associated with Gleason upgrading. This information was used to develop a nomogram to predict for upgrading or treatment in patients electing for active surveillance. RESULTS: Of 862 patients in our cohort 592 had 2 or more biopsies. Median followup was 6.4 years. Of the patients 20% were intermediate risk, 0.3% were high risk and all others were low risk. During active surveillance 31.3% of cases were upgraded. On multivariate analysis clinical stage T2, higher prostate specific antigen and higher percentage of cores involved with disease at the time of diagnosis predicted for upgrading. A total of 27 cases (15% of those upgraded) were Gleason 8 or higher at upgrading, and 62% of all 114 upgraded cases went on to have active treatment. The nomogram incorporated clinical stage, age, prostate specific antigen, core positivity and Gleason score. The concordance index was 0.61. CONCLUSIONS: In this large re-biopsy cohort with medium-term followup, most cases have not been pathologically upgraded to date. A model predicting for upgrading or radical treatment was developed which could be useful in counseling patients considering active surveillance for prostate cancer.

Early Attachment and the Development of Social Communication: A Neuropsychological Approach.

Social communication forms the foundation of human relationships. Social communication, i.e., the appropriate understanding and use of verbal and non-verbal communication within a social context, profoundly impacts mental health across the lifespan and is also highly vulnerable to neurodevelopmental threats and social adversities. There exists a strong interconnection between the development of language and other higher cognitive skills, mediated, in part, through the early attachment relationship. Consideration of how attachment links to brain development can help us understand individuals with social communication difficulties across the lifespan. The early attachment relationship supports the development of the foundational constructs of social communication. In this paper, a neuropsychological perspective was applied to social communication, which integrated evidence from early attachment theory, examining the underpinnings of social communication components identified by the SoCom model, namely socio-cognitive, socio-emotional, and socio-linguistic constructs. A neuropsychological perspective underscores the importance of interdisciplinary collaboration. This should also inform approaches to prevention, policy, intervention, and advocacy for individuals with or at risk for social communication impairments, as well as their families.

Corrigendum: Early attachment and the development of social communication: A neuropsychological approach.

[This corrects the article DOI: 10.3389/fpsyt.2022.838950.].

Parent-child interaction in motor speech therapy.

PURPOSE: This study measures the reliability and sensitivity of a modified Parent-Child Interaction Observation scale (PCIOs) used to monitor the quality of parent-child interaction. The scale is part of a home-training program employed with direct motor speech intervention for children with speech sound disorders. METHOD: Eighty-four preschool age children with speech sound disorders were provided either high- (2×/week/10 weeks) or low-intensity (1×/week/10 weeks) motor speech intervention. Clinicians completed the PCIOs at the beginning, middle, and end of treatment. Inter-rater reliability (Kappa scores) was determined by an independent speech-language pathologist who assessed videotaped sessions at the midpoint of the treatment block. Intervention sensitivity of the scale was evaluated using a Friedman test for each item and then followed up with Wilcoxon pairwise comparisons where appropriate. RESULTS: We obtained fair-to-good inter-rater reliability (Kappa = 0.33-0.64) for the PCIOs using only video-based scoring. Child-related items were more strongly influenced by differences in treatment intensity than parent-related items, where a greater number of sessions positively influenced parent learning of treatment skills and child behaviors. CONCLUSION: The adapted PCIOs is reliable and sensitive to monitor the quality of parent-child interactions in a 10-week block of motor speech intervention with adjunct home therapy. Implications for rehabilitation Parent-centered therapy is considered a cost effective method of speech and language service delivery. However, parent-centered models may be difficult to implement for treatments such as developmental motor speech interventions that require a high degree of skill and training. For children with speech sound disorders and motor speech difficulties, a translated and adapted version of the parent-child observation scale was found to be sufficiently reliable and sensitive to assess changes in the quality of the parent-child interactions during intervention. In developmental motor speech interventions, high-intensity treatment (2×/week/10 weeks) facilitates greater changes in the parent-child interactions than low intensity treatment (1×/week/10 weeks). On one hand, parents may need to attend more than five sessions with the clinician to learn how to observe and address their child's speech difficulties. On the other hand, children with speech sound disorders may need more than 10 sessions to adapt to structured play settings even when activities and therapy materials are age-appropriate.

Understanding Partnerships With Patients/Clients in a Team Context Through Verbatim Theater.

Introduction: Patient partnership has come to the forefront in health care practice and education, influencing professional programs and interprofessional education curricula. While students conceptually understand the idea of partnering with the patient, the practice of doing so is more challenging. Innovative ways to teach this health care approach may be effective in enabling students to apply their learning and promote enhanced patient partnerships. This resource provides an arts-based approach for exploring notions of partnerships with patients in a team context with interprofessional collaboration. Method: This 2-hour resource features a verbatim reader's theater script and accompanying discussion questions for a small-group reading and debrief activity. The voice of individuals with lived experience is elevated to enhance student learning and connection to the topic. Quotations were taken from interviews with individuals who had experience with the health care system and from health care providers. Results: The script and accompanying small-group discussion questions have been used in the interprofessional education curriculum with approximately 1,100 health profession students. Student response has been positive, indicating a new appreciation for thinking about partnering with patients. Discussion: Although the script has been used in the context of interprofessional education, it has the potential to be used as part of uniprofessional teaching and in practice environments, since understanding the nature of partnerships between practitioners and patients transcends all settings.

Listeners learn phonotactic patterns conditioned on suprasegmental cues.

Language learners are sensitive to phonotactic patterns from an early age, and can acquire both simple and 2nd-order positional restrictions contingent on segment identity (e.g., /f/ is an onset with /æ/but a coda with /ɪ/). The present study explored the learning of phonototactic patterns conditioned on a suprasegmental cue: lexical stress. Adults first heard non-words in which trochaic and iambic items had different consonant restrictions. In Experiment 1, participants trained with phonotactic patterns involving natural classes of consonants later falsely recognized novel items that were consistent with the training patterns (legal items), demonstrating that they had learned the stress-conditioned phonotactic patterns. However, this was only true for iambic items. In Experiment 2, participants completed a forced-choice test between novel legal and novel illegal items and were again successful only for the iambic items. Experiment 3 demonstrated learning for trochaic items when they were presented alone. Finally, in Experiment 4, in which the training phase was lengthened, participants successfully learned both sets of phonotactic patterns. These experiments provide evidence that learners consider more global phonological properties in the computation of phonotactic patterns, and that learners can acquire multiple sets of patterns simultaneously, even contradictory ones.

Long-term follow-up of a large active surveillance cohort of patients with prostate cancer.

PURPOSE: Active surveillance is increasingly accepted as a treatment option for favorable-risk prostate cancer. Long-term follow-up has been lacking. In this study, we report the long-term outcome of a large active surveillance protocol in men with favorable-risk prostate cancer. PATIENTS AND METHODS: In a prospective single-arm cohort study carried out at a single academic health sciences center, 993 men with favorable- or intermediate-risk prostate cancer were managed with an initial expectant approach. Intervention was offered for a prostate-specific antigen (PSA) doubling time of less than 3 years, Gleason score progression, or unequivocal clinical progression. Main outcome measures were overall and disease-specific survival, rate of treatment, and PSA failure rate in the treated patients. RESULTS: Among the 819 survivors, the median follow-up time from the first biopsy is 6.4 years (range, 0.2 to 19.8 years). One hundred forty-nine (15%) of 993 patients died, and 844 patients are alive (censored rate, 85.0%). There were 15 deaths (1.5%) from prostate cancer. The 10- and 15-year actuarial cause-specific survival rates were 98.1% and 94.3%, respectively. An additional 13 patients (1.3%) developed metastatic disease and are alive with confirmed metastases (n = 9) or have died of other causes (n = 4). At 5, 10, and 15 years, 75.7%, 63.5%, and 55.0% of patients remained untreated and on surveillance. The cumulative hazard ratio for nonprostate-to-prostate cancer mortality was 9.2:1. CONCLUSION: Active surveillance for favorable-risk prostate cancer is feasible and seems safe in the 15-year time frame. In our cohort, 2.8% of patients have developed metastatic disease, and 1.5% have died of prostate cancer. This mortality rate is consistent with expected mortality in favorable-risk patients managed with initial definitive intervention.

Improved wait time intervals for prostate cancer patients in a multidisciplinary rapid diagnostic unit compared to a community-based referral pattern.

BACKGROUND: Wait times in cancer diagnosis and treatment may significantly affect a patient's treatment outcome, prognosis and quality of life. The purpose of this study was to capture wait time intervals for patients with prostate cancer treated with radiotherapy (RT) at the Odette Cancer Centre, Toronto, Ontario, Canada and to compare patients diagnosed in a rapid diagnostic unit (RDU) versus the usual community referral process. METHODS: Patients agreed to participate in the study during their RT planning sessions. A semi-structured interview and chart abstraction was conducted to record key wait time milestones. RESULTS: A total of 87 patients participated in the study: 44 RDU patients and 43 community patients. The median overall wait time intervals from suspicion of prostate cancer to RT was 138 and 183 days, respectively (p = 0.046). There were statistically significant differences observed for other key wait time intervals favouring the RDU cohort: suspicion to decision-to-treat (DTT; p = 0.012), urologist visit to diagnosis (p = 0.0094), diagnosis to DTT (p = 0.018), and diagnosis to treatment (p = 0.016). Risk category and Gleason sum was independently predictive of longer intervals from diagnosis to DTT. INTERPRETATION: Wait time intervals from suspicion to treatment are significantly shorter for prostate cancer patients in 2011 to 2012 than in 2003 when patients were diagnosed and referred in the community setting. A prostate-specific RDU further reduced a number of key wait time intervals supporting more multidisciplinary RDUs for common diseases. Further work needs to be done to identify why delays are occurring and to develop new processes to minimize delays.

Utility of 5-alpha-reductase inhibitors in active surveillance for favourable risk prostate cancer.

INTRODUCTION: This retrospective review compares prostate-specific antigen (PSA) doubling time (DT) prior to the initiation of a 5-alpha-reductase inhibitor (pre-5-ARI) to after the PSA nadir (post-nadir) has been reached for patients on active surveillance for favourable-risk prostate cancer. METHODS: Between 1996 and 2010, a total of 100 men with a history of 5-ARI use were captured from our active surveillance database. Twenty-nine patients had a sufficient number of PSA values to determine both pre-5-ARI and post-nadir DTs. PSADT was calculated using the general linear mixed-model method. RESULTS: The median follow-up was 69.5 months. The median pre-5-ARI PSADT was 55.8 (range: 6-556.8) months, while the post-nadir value was 25.2 (range: 6-231) months (p = 0.0081). Six patients were reclassified after an average of 67.7 (range: 59-95) months, due to progression in PSADT (n = 2) or Gleason score (n = 4). The median pre-5-ARI and post-nadir DTs for this group were 42.3 (range: 32.4-91.1) and 21.1 (range: 6-44.3) months, respectively. CONCLUSION: 5-ARIs significantly decreased PSADT compared to prior to their initiation. This effect may be due to preferential suppression of benign tissue following PSA nadir. The resulting PSADT would then represent a more accurate depiction of the true cancer-related DT. If validated with a larger cohort, 5-ARIs may enhance the utility of PSADT as a biomarker of disease progression in active surveillance.