DNA methylation markers for risk of metastasis in a cohort of men with localized prostate cancer.

Accurately identifying life-threatening prostate cancer (PCa) at time of diagnosis remains an unsolved problem. We evaluated whether DNA methylation status of selected candidate genes can predict the risk of metastasis beyond clinical risk factors in men with untreated PCa. A nested case-control study was conducted among men diagnosed with localized PCa at Kaiser Permanente California between 01/01/1997-12/31/2006 who did not receive curative treatments. Cases were those who developed metastasis within 10 years from diagnosis. Controls were selected using density sampling. Ninety-eight candidate genes were selected from functional categories of cell cycle control, metastasis/tumour suppressors, cell signalling, cell adhesion/motility/invasion, angiogenesis, and immune function, and 41 from pluripotency genes. Cancer DNA from diagnostic biopsy blocks were extracted and analysed. Associations of methylation status were assessed using CpG site level and principal components-based analysis in conditional logistic regressions. In 215 cases and 404 controls, 27 candidate genes were found to be statistically significant in at least one of the two analytical approaches. The agreement between the methods was 25.9% (7 candidate genes, including 2 pluripotency markers). The DNA methylation status of several candidate genes was significantly associated with risk of metastasis in untreated localized PCa patients. These findings may inform future risk prediction models for PCa metastasis beyond clinical characteristics.

Genome-wide methylation profiling of diagnostic tumor specimens identified DNA methylation markers associated with metastasis among men with untreated localized prostate cancer.

BACKGROUND: We used a genome-wide discovery approach to identify methylation markers associated with metastasis in men with localized prostate cancer (PCa), as better identification of those at high risk of metastasis can inform treatment decision-making. METHODS: We identified men with localized PCa at Kaiser Permanente California (January 1, 1997-December 31, 2006) who did not receive curative treatment and followed them for 10 years to determine metastasis status. Cases were chart review-confirmed metastasis, and controls were matched using density sampling. We extracted DNA from the cancerous areas in the archived diagnostic tissue blocks. We used Illumina's Infinium MethylationEPIC BeadChip for methylation interrogation. We used conditional logistic regression and Bonferroni's correction to identify methylation markers associated with metastasis. In a separate validation cohort (2007), we evaluated the added predictive utility of the methylation score beyond clinical risk score. RESULTS: Among 215 cases and 404 controls, 31 CpG sites were significantly associated with metastasis status. Adding the methylation score to the clinical risk score did not meaningfully improve the c-statistic (0.80-0.81) in the validation cohort, though the score itself was statistically significant (p < 0.01). In the validation cohort, both clinical risk score alone and methylation marker score alone are well calibrated for predicted 10-year metastasis risks. Adding the methylation score to the clinical risk score only marginally improved predictive risk calibration. CONCLUSION: Our findings do not support the use of these markers to improve clinical risk prediction. The methylation markers identified may inform novel hypothesis in the roles of these genetic regions in metastasis development.

Exposure to statins post localized prostate cancer diagnosis and risk of metastasis among men who did not receive curative prostate cancer treatment.

BACKGROUND: Few studies have evaluated the effect of statin exposure on metastasis risk among prostate cancer patients not receiving curative treatment. METHODS: We included men diagnosed with localized prostate cancer at an integrated health care system between 1997 and 2006 who did not receive curative treatment within 6 months of diagnosis. We followed these men until a metastatic event, disenrollment, death, or 12/31/2016. We collected all data from electronic health records supplemented by chart review. We used Cox regressions to examine the association between post-diagnostic statin exposure and metastasis, controlling for clinical characteristics and pre-diagnostic statin exposure. RESULTS: There were 4245 men included. Mean age of diagnosis was 68.02 years. 46.6% of men used statins after prostate cancer diagnosis. During follow-up, 192 men developed metastasis (cumulative incidence rate: 14.5%). In the adjusted Cox model, statin use post-prostate cancer diagnosis was not significantly associated with a metastatic event (HR = 0.97, 95% CI = 0.69, 1.36). Pre-diagnostic statin use was also not associated with development of metastasis (HR = 0.76, 95% CI = 0.53, 1.10). We did not observe a dose-response for the proportion of person-time at-risk post-prostate cancer diagnosis on statins (HR = 0.98 per 10% increase in person-time exposed [95% CI = 0.93, 1.03]). CONCLUSIONS: We did not find an inverse association between post-diagnosis statin exposure and metastasis development in localized prostate cancer patients who did not receive active treatment. Our results did not offer support to the chemopreventive potential of post-diagnostic statin use among men on active surveillance.

Decision regret, adverse outcomes, and treatment choice in men with localized prostate cancer: Results from a multi-site randomized trial.

INTRODUCTION: Men diagnosed with localized prostate cancer must navigate a highly preference-sensitive decision between treatment options with varying adverse outcome profiles. We evaluated whether use of a decision support tool previously shown to decrease decisional conflict also impacted the secondary outcome of post-treatment decision regret. METHODS: Participants were randomized to receive personalized decision support via the Personal Patient Profile-Prostate or usual care prior to a final treatment decision. Symptoms were measured just before randomization and 6 months later; decision regret was measured at 6 months along with records review to ascertain treatment choices. Regression modeling explored associations between baseline variables including race and D`Amico risk, study group, and 6-month variables regret, choice, and symptoms. RESULTS: At 6 months, 287 of 392 (73%) men returned questionnaires of which 257 (89%) had made a treatment choice. Of that group, 201 of 257 (78%) completely answered the regret scale. Regret was not significantly different between participants randomized to the P3P intervention compared to the control group (P = 0.360). In univariate analyses, we found that Black men, men with hormonal symptoms, and men with bowel symptoms reported significantly higher decision regret (all P < 0.01). Significant interactions were detected between race and study group (intervention vs. usual care) in the multivariable model; use of the Personal Patient Profile-Prostate was associated with significantly decreased decisional regret among Black men (P = 0.037). Interactions between regret, symptoms and treatment revealed that (1) men choosing definitive treatment and reporting no hormonal symptoms reported lower regret compared to all others; and (2) men choosing active surveillance and reporting bowel symptoms had higher regret compared to all others. CONCLUSION: The Personal Patient Profile-Prostate decision support tool may be most beneficial in minimizing decisional regret for Black men considering treatment options for newly-diagnosed prostate cancer. TRIAL REGISTRATION: NCT01844999.

Neoadjuvant Leuprolide Therapy with Radical Prostatectomy: Long-term Effects on Health-related Quality of Life.

BACKGROUND: Neoadjuvant androgen ablation (neoadjuvant androgen deprivation therapy [NADT]) is used prior to radical prostatectomy, contrary to guidelines, but its long-term effects on quality of life is unknown. OBJECTIVE: To determine the effect of NADT on patient's long-term recovery following surgery. DESIGN, SETTING, AND PARTICIPANTS: From March 2011 to August 2013, 5808 men with newly diagnosed prostate were followed up to 24 mo. A cohort of men who received NADT prior to robotic-assisted laparoscopic prostatectomy (RALP; n=51) was compared 1:3 with a matched group that underwent RALP only (n=153). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Patients were matched on Charlson comorbidities, biopsy Gleason score, and node status on final pathology. The Kruskall-Wallis test was used to compare the groups on their bowel, urinary, sexual, and hormonal domains of the 26-item Expanded Prostate Cancer Index Composite at baseline and at 1, 3, 6, 12, 18, and 24 mo postoperatively. RESULTS AND LIMITATIONS: The urinary irritative, urinary incontinence, and bowel domains were similar in the two groups during the 24 mo (p=0.832, 0.901, and 0.732, respectively). In the hormonal domain, the NADT group did worse (p<0.001). The sexual domain was also worse for the NADT group. However, when accounting for nerve sparing, there was no significant difference in sexual outcomes between the two groups (p=0.069). CONCLUSIONS: Patients who received NADT prior to RALP do not have worse sexual function, but have worse hormonal scores for up to 2yr after surgery. PATIENT SUMMARY: Neoadjuvant androgen deprivation therapy (NADT) is administered prior to robotic-assisted laparoscopic prostatectomy (RALP), contrary to clinical guidelines. NADT may not have worse sexual function outcomes up to 2yr after RALP.

Physician Compliance to Choosing Wisely® Initiative in Radiographic Imaging of Low Risk Prostate Cancer in an Integrated Health Care System.

INTRODUCTION: We evaluated the adherence of urologists within an integrated health care system to Choosing Wisely®, an initiative aimed at avoiding unnecessary medical tests. In urology, 2 of the guidelines state bone scans and pelvic computerized tomography scans are unnecessary in low risk prostate cancer. METHODS: We performed a retrospective study on patients diagnosed with low risk prostate cancer between January 1, 2010 and December 31, 2017 at Kaiser Permanente Southern California. All demographics and imaging data were obtained. Patients with symptoms concerning for metastatic disease or with other malignancies were excluded by chart review. Statistical analysis was employed to compare the use of bone scans and computerized tomography scans in this population before and after the Choosing Wisely guidelines were published. RESULTS: Of the 6,996 patients, 121 (1.7%) and 96 (1.4%) underwent a bone scan and computerized tomography scan, respectively. A Cochran-Armitage test showed no change after implementation of the statements. Logistic regression analysis revealed that for every point increase in prostate specific antigen, the odds ratio was 1.09 for ordering both a bone scan and computerized tomography scan. When compared to Whites, the odds ratio of having a bone scan and computerized tomography scan were 0.35 and 0.37 for Blacks, 0.30 and 0.38 for Hispanics, and 0.47 and 0.61 for Asians, respectively. CONCLUSIONS: Over the study period, there were low rates of inappropriate imaging for low risk prostate cancer. There was no change in trend after publication of the Choosing Wisely. Higher prostate specific antigen levels and White ethnicity were predictors for ordering inappropriate imaging.

Long-term follow-up of a racially and ethnically diverse population of men with localized prostate cancer who did not undergo initial active treatment.

BACKGROUND: There is limited research on the racial/ethnic differences in long-term outcomes for men with untreated, localized prostate cancer. METHODS: Men diagnosed with localized, Gleason ≤7 prostate cancer who were not treated within 1 year of diagnosis from 1997-2007 were identified. Cumulative incidence rates of the following events were calculated; treatment initiation, metastasis, death due to prostate cancer and all-cause mortality, accounting for competing risks. The Cox model of all-cause mortality and Fine-Gray sub distribution model to account for competing risks were used to test for racial/ethnic differences in outcomes adjusted for clinical factors. RESULTS: There were 3925 men in the study, 749 Hispanic, 2415 non-Hispanic white, 559 non-Hispanic African American, and 202 non-Hispanic Asian/Pacific Islander (API). Median follow-up was 9.3 years. At 19 years, overall cumulative incidence of treatment, metastasis, death due to prostate cancer, and all-cause mortality was 25.0%, 14.7%, 11.7%, and 67.8%, respectively. In adjusted models compared to non-Hispanic whites, African Americans had higher rates of treatment (HR = 1.39, 95% CI = 1.15-1.68); they had an increased risk of metastasis beyond 10 years after diagnosis (HR = 4.70, 95% CI = 2.30-9.61); API and Hispanic had lower rates of all-cause mortality (HR = 0.66, 95% CI = 0.52-0.84, and HR = 0.72, 95% CI = 0.62-0.85, respectively), and API had lower rates of prostate cancer mortality in the first 10 years after diagnosis (HR = 0.29, 95% CI = 0.09-0.90) and elevated risks beyond 10 years (HR = 5.41, 95% CI = 1.39-21.11). CONCLUSIONS: Significant risks of metastasis and prostate cancer mortality exist in untreated men beyond 10 years after diagnosis, but are not equally distributed among racial/ethnic groups.

Assigning value to preparation for prostate cancer decision making: a willingness to pay analysis.

BACKGROUND: The Personal Patient Profile-Prostate (P3P) is a web-based decision support system for men newly diagnosed with localized prostate cancer that has demonstrated efficacy in reducing decisional conflict. Our objective was to estimate willingness-to-pay (WTP) for men's decisional preparation activities. METHODS: In a multicenter, randomized trial of P3P, usual care group participants received typical preparation for decision making plus referral to publicly-available, educational websites. Intervention group participants received the same, plus online P3P educational media specific to the user's personal preferences and values, and a communication coaching component tailored to race\ethnicity, age and language. WTP data were collected one week after physician consultation. An iterative bidding direct contingent valuation survey format was used, randomly assigning participants to high or low starting values (SV). Tobit models were used to explore associations between SV-adjusted WTP and age, education, marital and work-status, insurance, decision-control preference and decision-making stage. RESULTS: Of 392 participants enrolled, 141 P3P and 107 usual care (UC) provided a WTP value. Men were willing to pay a median $25 (IQR $10-100) for P3P in addition to usual care preparation materials. In the final multivariable tobit regression model, SV, marital status, stage of decision making and income were significantly associated with WTP for P3P. Decision control preference was considered marginally significant (p = 0.11). Men were WTP a median $30 (IQR $10-$200) for usual care material alone. In the final multivariable model, SV, education, and stage of decision making were significantly associated with WTP in usual care. CONCLUSION: WTP was similar for UC and for the addition of P3P to UC decision preparation. The WTP values were associated with demographic and preference variables. Findings can help focus decision support on future patients who would benefit most: those without strong support systems, at earlier stages of decision making, and open to a shared-decision style. TRIAL REGISTRATION: NCT NCT01844999 . Registered May 3, 2013.

Trend of Surgical Treatment of Localized Renal Cell Carcinoma.

INTRODUCTION: Rapid adoption of robotics has introduced a paradigm change in prostate cancer treatment, with more than 80% of prostatectomies performed robotically in 2015. For treatment of renal cell carcinoma (RCC), this change has not previously been reported. We evaluated trends in surgical management of RCC in Kaiser Permanente Southern California (KPSC) within the last 16 years, especially after adoption of robotics. METHODS: From January 1999 to September 2015, all KPSC members who underwent surgical treatment of suspected RCC were included retrospectively. Surgical approach, patient age, sex, clinicopathology, Charlson Comorbidity Index, and chronic kidney disease status were analyzed using robust Poisson multivariate regression. RESULTS: The study included 5237 patients. Partial nephrectomy was increasingly used during the study period, and its use surpassed radical nephrectomy in 2012. In a multivariate model, partial nephrectomy was associated with lower pathologic tumor stage (p < 0.001) and lower Charlson Comorbidity Index (p = 0.004) vs radical nephrectomy. Robot-assisted laparoscopic partial nephrectomy (RALPN) started in KPSC in March 2011, and its relative use among all RCC surgeries increased in the following 3 years by 125%, 45%, and 14%. Laparoscopic partial nephrectomy and laparoscopic radical nephrectomy were the most frequently used surgical approaches for localized RCC when RALPN started in 2011. However, RALPN surpassed laparoscopic partial nephrectomy and laparoscopic radical nephrectomy in 2012 and 2014, respectively. CONCLUSION: During our study, partial nephrectomy became the most common surgery for treatment of localized RCC. Since 2014, RALPN has become the most common renal oncologic surgical modality in KPSC.

Evaluating Clinical Implementation Approaches for Prostate Cancer Decision Support.

INTRODUCTION: Shared decision making is widely promoted for counseling men with localized prostate cancer. Results of randomized trials suggest decision aid efficacy. However, few practices or institutions have implemented decision support as standard practice. In this study we evaluated various implementation strategies for the decision aid P3P (Personal Patient Profile-Prostate) and analyzed feedback from clinical site staff and providers. METHODS: A hybrid type 1 effectiveness-implementation trial was conducted. Primary data were collected in 6 urology clinics of 3 geographically distinct health networks. During the implementation phase site specific strategies were codesigned with site leaders. Referral and access metrics for men with localized prostate cancer were monitored for up to 7 months. Clinical staff reports of barriers and facilitators of implementation were evaluated in professionally facilitated focus groups. RESULTS: Of 495 men with localized prostate cancer seen in the clinics 252 (51%, 95% CI 46-55) were informed of the program and of those men 107 (43%, 95% CI 36-49) accessed it. The highest access rates were observed with patient care coordinator e-mail and telephone contact (82%) or verbal physician instruction followed by e-mail and telephone invitations (87%). During focus groups physicians appraised the summaries as useful. Staff identified barriers included creating new workflows within heavy workloads and staff misunderstanding of context and resources. Promoters of successful implementation included an identified clinical lead and physician engagement. CONCLUSIONS: Implementation success was realized when physicians engaged and staff provided followup contact. New practice changes to implement interventions require multimodal strategies for early success.

Nephrometry score matched robotic vs. laparoscopic vs. open partial nephrectomy.

To compare perioperative outcomes in the three most common partial nephrectomy modalities: robotic (RPN), laparoscopic (LPN), and open (OPN), matched for nephrometry scores. Patients aged 16-85 who underwent RPN, LPN, or OPN from 2007 to 2014 for localized renal carcinoma within our healthcare system were enrolled. Age, sex, body mass index, and Charlson Comorbidity Index (CCI) as well as perioperative outcomes of estimated blood loss (EBL), length of hospital stay (LOS), ischemia time (IT), change in eGFR, positive margin rate, operative time (OT), and emergency room visit rates were compared between RPN, LPN, and OPN using the R.E.N.A.L nephrometry score. A total of 862 patients underwent partial nephrectomy (523 LPN, 176 OPN, and 163 RPN). Patients who underwent OPN were significantly older, and had higher nephrometry scores and CCI. When matched for nephrometry scores, minimally invasive (LPN and RPN) compared to OPN had lower EBL (< 0.0001), shorter LOS (< 0.0001), shorter IT (< 0.001), and less change in eGFR (< 0.001), particularly in nephrometry scores higher than 8 (0.0099). Comparing RPN with LPN, RPN had significantly shorter OT in all nephrometry scores (< 0.001); shorter IT and LOS in nephrometry scores higher than 7. Our study suggests that minimally invasive partial nephrectomy may have superior outcomes to OPN when matched by nephrometry scores, particularly at higher scores and for RPN. This finding may contribute to a surgeon's decision in the approach to partial nephrectomy.

Decision Support with the Personal Patient Profile-Prostate: A Multicenter Randomized Trial.

PURPOSE: We evaluated the efficacy of the web based P3P (Personal Patient Profile-Prostate) decision aid vs usual care with regard to decisional conflict in men with localized prostate cancer. MATERIALS AND METHODS: A randomized (1:1), controlled, parallel group, nonblinded trial was performed in 4 regions of the United States. Eligible men had clinically localized prostate cancer and an upcoming consultation, and they spoke and read English or Spanish. Participants answered questionnaires to report decision making stage, personal characteristics, concerns and preferences plus baseline symptoms and decisional conflict. A randomization algorithm allocated participants to receive tailored education and communication coaching, generic teaching sheets and external websites plus a 1-page summary to clinicians (intervention) or the links plus materials provided in clinic (usual care). Conflict outcomes and the number of consultations were measured at 1 month. Univariate and multivariable models were used to analyze outcomes. RESULTS: A total of 392 men were randomized, including 198 to intervention and 194 to usual care, of whom 152 and 153, respectively, returned 1-month outcomes. The mean ± SD 1-month decisional conflict scale (score range 0 to 100) was 10.9 ± 16.7 for intervention and 9.9 ± 18.0 for usual care. The multivariable model revealed significantly reduced conflict in the intervention group (-5.00, 95% CI -9.40--0.59). Other predictors of conflict included income, marital or partner status, decision status, number of consultations, clinical site and D'Amico risk classification. CONCLUSIONS: In this multicenter trial the decision aid significantly reduced decisional conflict. Other variables impacted conflict and modified the effect of the decision aid, notably risk classification, consultations and resources. P3P is an effective adjunct for shared decision making in men with localized prostate cancer.

Healthcare utilization in men with poorer sexual and urinary function recovery following robot-assisted radical prostatectomy.

PURPOSE: Robotic radical prostatectomy focuses on oncologic cure, urinary continence and sexual function recovery. However, little is known about the effect of declines in urinary continence and sexual function on healthcare utilization. We aim to identify these factors. MATERIALS AND METHODS: From March 2011 to September 2013, all men undergoing robotic prostatectomy within our healthcare system were enrolled. Men completed the expanded prostate cancer index composite-26 survey at the time of diagnosis and 90 days post-operatively. Patients were stratified according to change in scores in the sexual function and urinary incontinence domains. Patient, treatment and post-op utilization patterns were examined for association with the extent of decline in sexual function and urinary continence. Multivariate linear regression was used to identify factors independently associated with decline in continence and sexual function. RESULTS: A total of 411 men who completed the baseline survey and at 90 days postoperatively were included. On multivariate linear regression, younger age (p < 0.01), higher preoperative sexual function (< 0.01), single marital status (p = 0.04) and more post-surgery email contacts (p = 0.04) were associated with higher declines in sexual function. For continence, no family history of prostate cancer (p = 0.01), higher baseline continence (p < 0.01) and more post-surgery physical therapy visits (p < 0.01) were associated with higher declines. CONCLUSIONS: Patients with the poorest quality of life outcomes at 90 days post-operatively were more likely to seek care via email and physical therapy encounters related to sexual function and urinary incontinence, respectively. This suggests that maximizing post-treatment quality of life can potentially reduce healthcare utilization.

Racial and Ethnic Variation in Health-Related Quality of Life Scores Prior to Prostate Cancer Treatment.

INTRODUCTION: Many men diagnosed with prostate cancer are concerned with how the disease and its course of treatment could affect their health-related quality of life (HRQOL). To aid in the decision-making process on a course of treatment and to better understand how these treatments can affect HRQOL, knowledge of pretreatment HRQOL is essential. AIMS: To assess the racial and ethnic variations in HRQOL scores in men newly diagnosed with prostate cancer before electing a course of treatment. METHODS: Male members of the Kaiser Permanente of Southern California health plan who were newly diagnosed with prostate cancer completed the five-domain specific Expanded Prostate Index Composite-26 (EPIC-26) HRQOL questionnaire from March 1, 2011 through August 31, 2013 (N = 2,579). Domain scores were compared across racial and ethnic subgroups and multiple logistic regression analyses were used to assess the association after adjusting for sociodemographic and clinical characteristics. MAIN OUTCOME MEASURES: The five EPIC-26 domain scores (sexual, bowel, hormonal, urinary incontinence, and urinary irritation and obstruction). RESULTS: Results from the fully adjusted analyses indicated that non-Hispanic black men were more likely to be above the sample median on the sexual (odds ratio [OR] = 1.43, 95% CI = 1.09-1.88), hormonal (OR = 1.35, 95% CI = 1.03-1.77), and urinary irritation and obstruction (OR = 1.34, 95% CI = 1.03-1.74) domains compared with non-Hispanic white men. The Asian or Pacific Islander men were less likely to be above the sample median on the sexual domain (OR = 0.60, 95% CI = 0.44-0.83) compared with non-Hispanic white men. No additional statistically significant differences were identified. CONCLUSIONS: Within an integrated health care organization, we found minimal racial and ethnic differences, aside from sexual function, in pretreatment HRQOL in men newly diagnosed with prostate cancer. These findings provide important insight with which to interpret HRQOL changes in men newly diagnosed with prostate cancer during and after prostate cancer treatment. Reading SR, Porter KR, Slezak JM, et al. Racial and Ethnic Variation in Health-Related Quality of Life Scores Prior to Prostate Cancer Treatment. Sex Med 2017;5:e219-e228.

Effect of a Smoking Cessation Program on Sexual Function Recovery Following Robotic Prostatectomy at Kaiser Permanente Southern California.

INTRODUCTION: The association between cigarette smoking and erectile dysfunction has been well established. Studies demonstrate improvements in erectile rigidity and tumescence as a result of smoking cessation. Radical prostatectomy is also associated with worsening of erectile function secondary to damage to the neurovascular bundles. To our knowledge, no previous studies have examined the relationship between smoking cessation after prostate cancer diagnosis and its effect on sexual function following robotic prostatectomy. We sought to demonstrate the utility of a smoking cessation program among patients with prostate cancer who planned to undergo robotic prostatectomy at Kaiser Permanente Southern California. METHODS: All patients who underwent robotic prostatectomy between March 2011 and April 2013 with known smoking status were included, and were followed-up through November 2014. All smokers were offered the smoking cessation program, which included wellness coaching, tobacco cessation classes, and pharmacotherapy. Patients completed the Expanded Prostate Cancer Index Composite-26 (EPIC-26) health-related quality-of-life (HR-QOL) survey at baseline and postoperatively at 1, 3, 6, 12, 18, and 24 months. There were 2 groups based on smoking status: Continued smoking vs quitting group. Patient's age, Charlson Comorbidity Score, body mass index, educational level, median household income, family history of prostate cancer, race/ethnicity, language, nerve-sparing status, and preoperative/postoperative clinicopathology and EPIC-26 HR-QOL scores were examined. A linear regression model was used to predict sexual function recovery. RESULTS: A total of 139 patients identified as smokers underwent the smoking cessation program and completed the EPIC-26 surveys. Fifty-six patients quit smoking, whereas 83 remained smokers at last follow-up. All demographics and clinicopathology were matched between the 2 cohorts. Smoking cessation, along with bilateral nerve-sparing status, were the only 2 modifiable factors associated with improved sexual function after prostatectomy (6.57 points, p = 0.0226 and 8.97 points, p = 0.0485, respectively). CONCLUSION: In the setting of robotic prostatectomy, perioperative smoking cessation is associated with a significant improvement in long-term sexual functional outcome when other factors are adjusted.

Health-related quality of life outcomes from a contemporary prostate cancer registry in a large diverse population.

OBJECTIVE: To assess the health-related quality of life (HRQoL) of patients with prostate cancer up to 24 months after treatment in a contemporary large diverse population. PATIENTS AND METHODS: Patients with newly diagnosed prostate cancer from March 2011 to January 2014 in our healthcare system were included. The Expanded Prostate Cancer Index Composite (EPIC-26) questionnaire was administered before treatment, and at 1, 3, 6, 12, 18, and 24 months after treatment up to November 2014 for all methods of treatment. The Kruskall-Wallis test was used to compare the distribution of each EPIC-26 domain score at each time point, and mixed models were used to assess the overall scores over the period after treatment. RESULTS: In all, 5 727 patients were included. There were data for 3 422, 2 329, 2 017, 1 922, 1 772, 1 260, and 837 patients before treatment, and at 1, 3, 6, 12, 18, and 24 months after treatment, respectively. At 1 month, bowel scores were the lowest for patients that had had radiation therapy, and urinary irritative symptoms were the lowest for those who had had brachytherapy. There were sexual function declines for all the treatment methods, with surgery having the steepest decline; open radical prostatectomy (ORP) had a greater decline than robot-assisted laparoscopic prostatectomy (RALP). Patients who underwent RALP had a better return of sexual function, approaching that of brachytherapy and radiation therapy at 24 months. Urinary incontinence (UI) also declined the most in surgical patients, with RALP patients improving slightly more than ORP patients at 12-24 months. CONCLUSIONS: Patients' HRQoL after prostate cancer treatment varies by treatment method. Notably, sexual function recovers most for RALP patients. UI remains worse at 24 months after surgery, compared to other methods of prostate cancer treatment.

Does the Level of Assistant Experience Impact Operative Outcomes for Robot-Assisted Partial Nephrectomy?

PURPOSE: A skilled assistant surgeon is presumed necessary during robot-assisted partial nephrectomy (RAPN) to minimize warm ischemia time (WIT) and to facilitate complex renorrhaphy. Studies observing impact of resident participation have focused on robotic prostatectomies, showing no impact on core surgical outcomes. Herein, we evaluated the level of experience of the bedside assistant and its impact on perioperative outcomes in RAPN. MATERIALS AND METHODS: All RAPN cases in our healthcare system from January 2011 to December 2013 were retrospectively reviewed. The cases were divided into teaching and nonteaching hospitals. There were 18 fellowship-trained attending surgeons. At teaching hospitals, surgeries were performed by an attending physician and postgraduate year (PGY)-2 or PGY-3 resident at bedside; at nonteaching hospitals, surgeries were performed by two attending surgeons. We compared age, gender, body mass index, Charlson comorbidity index, operative difficulty by R.E.N.A.L. nephrometry score, and operative outcomes (WIT, estimated blood loss, operative time (OT), positive margin rate, length of stay (LOS), postoperative glomerular filtration rate, and readmission rate). RESULTS: Of the 170 patients captured, 162 had R.E.N.A.L. nephrometry score and WIT: 112 from teaching hospitals and 50 from nonteaching hospitals. Patient characteristics were equivalent between both cohorts with the exception of the R.E.N.A.L. score, which was higher (6.3 vs 5.7, p = 0.046) in the teaching hospitals cohort. Regarding operative outcomes, we noted an overall increase in LOS by 1 day (p = 0.001) and OT by 16 minutes (p = 0.011) in the teaching hospitals. CONCLUSION: We observed that increased LOS was the only clinically relevant measure negatively impacted by resident physician involvement during RAPN.

The effect of urologist experience on choosing active surveillance for prostate cancer.

PURPOSE: To evaluate the impact of the urologist's experience in selecting active surveillance (AS) versus immediate treatment (IT) for low-risk prostate cancer. METHODS: Men with low-risk prostate cancer were enrolled from March 2011 to August 2013 at 13 medical centers in Kaiser Permanente Southern California. The AS cohort was defined as men who had cT1-T2a stage prostate cancer, prostate-specific antigen <10 ng/ml, a biopsy revealing Gleason grade ≤6, fewer than three biopsy cores positive, ≤50 % cancer in any core, and not undergone immediate therapy (surgery, radiation, other) within 6 months following diagnosis. The urologist's experience (age, number of years in practice, number of robotic surgeries performed, and fellowship experience in oncology and/or robotics) was then compared between AS and IT cohorts. RESULTS: A total of 4754 men were diagnosed with prostate cancer, and 713 men satisfied with inclusion criteria; 433 (60.7 %) and 280 (39.3 %) chose AS and IT, respectively. A total of 87 urologists were included. Univariate and multivariate adjusted analyses revealed no differences in urologist's age or years in practice. Patients who saw urologists who had performed ≥50 robotic surgeries were less likely to choose AS (OR 0.40, 95 % CI 0.25-0.66). Patients who saw urologists with a fellowship in oncology and/or robotics were more than twice as likely to choose AS (OR 2.27, 95 % CI 1.38-3.75). CONCLUSION: These data suggest that the decision to pursue AS may be influenced by the urologist's experience.

Association between cannabis use and the risk of bladder cancer: results from the California Men's Health Study.

OBJECTIVE: To investigate the association of cannabis use and tobacco smoking on the incidence of bladder cancer within the California Men's Health Study cohort. METHODS: We evaluated the records of 84,170 participants in a multiethnic cohort of men aged 45-69 years. Information on demographic and lifestyle factors including smoking history and cannabis use was collected using mailed questionnaires between 2002 and 2003. We linked the study data with clinical records including cancer data from electronic health records. RESULTS: Overall 34,000 (41%) cohort members reported cannabis use, 47,092 (57%) reported tobacco use, 22,500 (27%) reported using both, and 23,467 (29%) used neither. Men were followed over an 11-year period and 279 (0.3%) developed incident bladder tumors. Among cannabis users, 89 (0.3%) developed bladder cancer in comparison to 190 (0.4%) men who did not report cannabis use (P < .001). After adjusting for age, race or ethnicity, and body mass index, using tobacco only was associated with an increased risk of bladder cancer (hazard regression [HR], 1.52; 95% confidence interval [CI], 1.12-2.07), whereas cannabis use only was associated with a 45% reduction in bladder cancer incidence (HR, 0.55; 95% CI, 0.31-1.00). Using both cannabis and tobacco was associated with an HR of 1.28 (95% CI, 0.91-1.80). CONCLUSION: Although a cause and effect relationship has not been established, cannabis use may be inversely associated with bladder cancer risk in this population.