Financial Toxicity Among Patients with Prostate, Bladder, and Kidney Cancer: A Systematic Review and Call to Action.

CONTEXT: Financial toxicity (FT) refers to the detrimental effects of financial strain caused by a cancer diagnosis on the well-being of patients and their families. It is highly prevalent among cancer patients and has been associated with inferior clinical outcomes. OBJECTIVE: To summarize the literature regarding FT among patients with prostate, bladder, and kidney cancer, and to propose a framework for future FT investigations. EVIDENCE ACQUISITION: Primary manuscripts and abstracts reporting FT as a primary or secondary outcome or a covariate in patients with prostate, bladder, or kidney cancer, published before May 2020, were retrieved using the PubMed, Scopus, Embase, CINAHL, and Cochrane databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Of 629 titles identified, 19, ten, and two studies met the inclusion criteria for prostate, bladder, and kidney cancer, respectively, and were included (24 unique articles). EVIDENCE SYNTHESIS: Significant heterogeneity was observed in covariates, methodology, and measure of FT. Factors commonly associated with FT included younger age at diagnosis, black race, low socioeconomic status, low education attainment, and rurality. FT was commonly associated with lower quality of life and nonadherence. FT was common among patients in countries with universal health coverage as well as those without, although the nature of these costs differed. CONCLUSIONS: Despite paucity of literature, it is suggested that FT is common among patients with prostate and bladder cancer, and remains uncharacterized in kidney cancer patients. Future work will benefit from the incorporation of a formal FT framework, utilization of validated FT instruments to characterize FT consistently, and inclusion of FT measures in outcomes reported by patients with genitourinary cancers. PATIENT SUMMARY: Financial toxicity affects many prostate, bladder, and kidney cancer patients; however, this toxicity is understudied. It is associated with decreased quality of life and lower medication and treatment adherence.

Full thickness penile skin necrosis following HIPEC: Case report and literature review.

Heated intraperitoneal chemotherapy (HIPEC) is commonly performed at the time of tumor resection for metastatic intraabdominal tumors. Post operative complications, such as superficial wound infections or bowel leaks are common. They are largely thought to be secondary to poor wound healing due to chemotherapy-associated neutropenia. Scrotal eschars resulting in full-thickness skin necrosis have rarely been reported as a delayed complication after HIPEC. Here, we present the first case report of penile full-thickness skin necrosis after abdominal cytoreduction with HIPEC combined with ventral hernia repair and mesh placement.

Incident testicular cancer in relation to using marijuana and smoking tobacco: A systematic review and meta-analysis of epidemiologic studies.

BACKGROUND: Recent epidemiologic studies identified credible associations between marijuana smoking and risk of nonseminomatous testicular germ cell tumors (TGCTs), but did not distinguish exposure to cannabinoid compounds from exposure to other constituents of smoke. METHODS: We implemented a systematic review of scholarly literature followed by random effects meta-analysis to quantitatively synthesize published data relating incident TGCT to each of 2 exposure histories: ever using marijuana, and ever smoking tobacco. RESULTS: We identified four epidemiologic studies of marijuana use and 12 of tobacco smoking. Summary data concur with earlier reports of a specific association of marijuana use with nonseminoma, summary odds ratio [sOR] = 1.71 (95% confidence interval [CI] 1.12-2.60), and identify a positive association, sOR = 1.18 (95% CI 1.05-1.33), between tobacco smoking and all TGCT. CONCLUSIONS: Available data accord with positive associations between incident TGCT and each exposure, implicating both cannabinoid compounds and other constituents of smoke. Etiologic interpretation awaits epidemiologic studies that assess associations between tobacco smoking and nonseminomatous TGCT, investigating not only these exposures but also both co-use of tobacco and marijuana and smoke-free sources of cannabinoids, while adequately evaluating potential confounding among all of these exposures.

Assessing the Impact of Time to Cystectomy for Variant Histology of Urothelial Bladder Cancer.

OBJECTIVE: To determine if the timing of radical cystectomy for variant histology of urothelial carcinoma has an impact on survival. Variant histology has been associated with aberrant behavior compared to pure urothelial carcinoma, however the timing of surgery for these patients has not been studied. MATERIALS AND METHODS: We identified 363 patients with cT2-T4N0M0 urothelial carcinoma who underwent radical cystectomy without perioperative intravesical and/or systemic therapy from 2003 to 2014. Clinicopathologic data were compared between pure urothelial carcinoma and variant histology. The time from diagnosis to radical cystectomy was analyzed as a continuous variable and dichotomized at 4-, 8-, and 12-weeks to determine impact on oncologic outcomes. RESULTS: Patients with variant histology, when compared to those with pure urothelial carcinoma, were more likely to present with extravesical disease (P <.01), be upstaged (P <.01), have lymphovascular invasion (P <.01) and have lymph node metastasis at radical cystectomy (P = .02). The median days to radical cystectomy did not differ between pure urothelial and variant histology. On multivariable analysis controlling for age, comorbidities, tumor stage, lymph node status, lymphovascular invasion, and surgical margins, every month in delay was associated with a worse overall survival for variants (HR = 1.36, P = .003). At an 8-week delay or longer, those with variant histology had a statistically worse survival (P = .03). CONCLUSION: For patients with variant histology, delays in surgery were associated with an increased risk of death.

Frailty and preoperative risk assessment before radical cystectomy.

PURPOSE OF REVIEW: The current review covers recent research examining the utility of preoperative frailty assessments to predict worse postoperative outcomes after radical cystectomy. It also discusses how to implement frailty assessments into routine clinical practice. RECENT FINDINGS: Frailty is associated with worse postoperative outcomes after radical cystectomy, including increased complications and nonhome discharge. Although the majority of these studies have been retrospective using a frailty index, prospective studies using a preoperative frailty assessment have also shown frailty to be associated with worse outcomes. Preoperative frailty assessments based on patients' physiologic fitness, such as the Fried Frailty Criteria or psoas muscle volume, have been the best predictors of worse outcomes on prospective cohorts. However, no study to date has directly compared a prospective frailty assessment and frailty index to determine the most effective tool for routine clinical care. National guidelines are lacking on how to assess frailty preoperatively before radical cystectomy. SUMMARY: Frailty has been consistently shown to correlate with worse postoperative outcomes after radical cystectomy. Although the most effective and efficient method for preoperative assessment has yet to be determined, assessments based on physiologic fitness are likely to be most useful. Improved guidelines will likely increase implementation of frailty assessments into routine management.

Frailty as a predictor of complications after radical cystectomy: A prospective study of various preoperative assessments.

PURPOSE: Frailty has been correlated with worse postoperative outcomes. Prospective studies examining frailty and bladder cancer are lacking. We aimed to determine whether a prospective frailty assessment or traditional risk indices can identify patients undergoing radical cystectomy (RC) at risk for complications. MATERIALS AND METHODS: Patients ≥65 years undergoing RC were preoperatively assessed using Fried Frailty Criteria (FFC; grip strength, gait speed, exhaustion, physical activity, shrinking), Charlson Comorbidity Index, American Society of Anesthesiologists score, Katz Index of Independence in Activities of Daily Living, Karnofsky Performance Scale, Eastern Cooperative Oncology Group performance status, and Center for Epidemiological Studies Depression scale. Thirty-day and 90-day postoperative complications were recorded. Univariate and multivariate analyses were performed. RESULTS: One hundred and twenty three patients were assessed with median age of 74 years. Fifty-nine patients (48.0%) had ≥1 complication within 30 days and 72 (58.5%) within 90 days. Center for Epidemiological Studies Depression scale (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.01-1.17, P = 0.027) and shrinking (OR 3.79, 95% CI 1.64-9.26, P = 0.0024) were significant for any 30-day complication, while physical activity was protective (OR 0.84, 95% CI 0.69-1.00, P = 0.072) for any 90-day complication. Being intermediately frail or frail was associated with high-grade 30-day (OR 4.87, 95% CI 1.39-22.77, P = 0.022) and 90-day complications (OR 3.01, 95% CI 1.05-9.37, P = 0.045), along with Eastern Cooperative Oncology Group score ≥3 (OR 45.00, 95% CI 6.92-437.69, P = 0.0010 and OR 17.85, 95% CI 3.21-143.26, P = 0.0079, respectively). CONCLUSIONS: Fried Frailty Criteria were predictive of high-grade complications, while individual components were predictive of having any complication. Elderly patients should be routinely assessed prior to RC to guide postoperative care.

Satisfaction With Testicular Prosthesis After Radical Orchiectomy.

OBJECTIVES: To determine patient satisfaction with testicular prostheses (TP) for testicular cancer. Reconstruction represents an important part of surgical oncology, yet placement of TP following orchiectomy is infrequently performed. Improved data on patient satisfaction with TP would help in counseling patients with testicular cancer. MATERIALS AND METHODS: Forty patients who underwent orchiectomy and TP placement for testicular cancer participated in a survey that was blinded to the providers in an outpatient clinic (2012-2014) to evaluate TP satisfaction. Categorical variables associated with satisfaction were compared using the Fisher's exact test. RESULTS: Median age at TP placement was 31 years (17-59). Most patients had their prosthesis in place for >1 year (81%) at the time of the survey. No patient reported complications from the TP and none underwent explantation. All patients felt that being offered an implant before orchiectomy was important. Overall, 33 patients (82.5%) rated the TP as good or excellent, and 35 men (87.5%) would have the prosthesis implanted again. Thirty-seven patients (92.5%) found the TP to be comfortable or very comfortable. However, 44% considered the TP too firm and 20% felt the position was not appropriate. Appropriate size, appropriate position, and TP comfort were significantly associated with good or excellent overall TP satisfaction (P < .05). CONCLUSION: Overall satisfaction with testicular implants after orchiectomy for testicular cancer is high. Patients should be offered a testicular prosthesis, especially at the time of orchiectomy. Efforts should be made to optimize implant firmness, and care should be given to proper size selection and positioning.

Paternal Risk Factors for Oral Clefts in Northern Africans, Southeast Asians, and Central Americans.

While several studies have investigated maternal exposures as risk factors for oral clefts, few have examined paternal factors. We conducted an international multi-centered case-control study to better understand paternal risk exposures for oral clefts (cases = 392 and controls = 234). Participants were recruited from local hospitals and oral cleft repair surgical missions in Vietnam, the Philippines, Honduras, and Morocco. Questionnaires were administered to fathers and mothers separately to elicit risk factor and family history data. Associations between paternal exposures and risk of clefts were assessed using logistic regression adjusting for potential confounders. A father's personal/family history of clefts was associated with significantly increased risk (adjusted OR: 4.77; 95% CI: 2.41-9.45). No other significant associations were identified for other suspected risk factors, including education (none/primary school v. university adjusted OR: 1.29; 95% CI: 0.74-2.24), advanced paternal age (5-year adjusted OR: 0.98; 95% CI: 0.84-1.16), or pre-pregnancy tobacco use (adjusted OR: 0.96; 95% CI: 0.67-1.37). Although sample size was limited, significantly decreased risks were observed for fathers with selected occupations. Further research is needed to investigate paternal environmental exposures as cleft risk factors.

Epidemiology, Etiology, and Treatment of Isolated Cleft Palate.

Isolated cleft palate (CPO) is the rarest form of oral clefting. The incidence of CPO varies substantially by geography from 1.3 to 25.3 per 10,000 live births, with the highest rates in British Columbia, Canada and the lowest rates in Nigeria, Africa. Stratified by ethnicity/race, the highest rates of CPO are observed in non-Hispanic Whites and the lowest in Africans; nevertheless, rates of CPO are consistently higher in females compared to males. Approximately fifty percent of cases born with cleft palate occur as part of a known genetic syndrome or with another malformation (e.g., congenital heart defects) and the other half occur as solitary defects, referred to often as non-syndromic clefts. The etiology of CPO is multifactorial involving genetic and environmental risk factors. Several animal models have yielded insight into the molecular pathways responsible for proper closure of the palate, including the BMP, TGF-ß, and SHH signaling pathways. In terms of environmental exposures, only maternal tobacco smoke has been found to be strongly associated with CPO. Some studies have suggested that maternal glucocorticoid exposure may also be important. Clearly, there is a need for larger epidemiologic studies to further investigate both genetic and environmental risk factors and gene-environment interactions. In terms of treatment, there is a need for long-term comprehensive care including surgical, dental and speech pathology. Overall, five main themes emerge as critical in advancing research: (1) monitoring of the occurrence of CPO (capacity building); (2) detailed phenotyping of the severity (biology); (3) understanding of the genetic and environmental risk factors (primary prevention); (4) access to early detection and multidisciplinary treatment (clinical services); and (5) understanding predictors of recurrence and possible interventions among families with a child with CPO (secondary prevention).