A qualitative approach to understanding the drivers of unequal receipt of definitive therapy for Black men with prostate cancer in Massachusetts.

BACKGROUND: Despite mandated insurance coverage since 2006 and robust health infrastructure in urban settings with high concentrations of minority patients, race-based disparities in prostate cancer (PCa) treatment persist in Massachusetts. In this qualitative study, the authors sought to identify factors driving inequities in PCa treatment in Massachusetts. METHODS: Four hospitals offering PCa treatment in Massachusetts were selected using a case-mix approach. Purposive sampling was used to conduct semistructured interviews with hospital stakeholders. Additional interviews were conducted with representatives from grassroots organizations providing PCa education. Two study staff coded the interviews to identify major themes and recurrent patterns. RESULTS: Of the 35 informants invited, 25 participated in the study. Although national disparities in PCa outcomes were readily discussed, one half of the informants were unaware that PCa disparities existed in Massachusetts. Informants and grassroots organization representatives acknowledged that patients with PCa are willing to face transportation barriers to receive treatment from trusted and accommodating institutions. Except for chief equity officers, most health care providers lacked knowledge on accessing or using metrics regarding racial disparities in cancer outcomes. Although community outreach was recognized as a potential strategy to reduce treatment disparities and engender trust, informants were often unable to provide a clear implementation plan. CONCLUSIONS: This statewide qualitative study builds on existing quantitative data on the nature and extent of disparities. It highlights knowledge gaps in recognizing and addressing racial disparities in PCa treatment in Massachusetts. Improved provider awareness, the use of disparity metrics, and strategic community engagement may ensure equitable access to PCa treatment. PLAIN LANGUAGE SUMMARY: Despite mandated insurance and urban health care access, racial disparities in prostate cancer treatment persist in Massachusetts. This qualitative study revealed that, although national disparities were acknowledged, awareness about local disparities are lacking. Stakeholders highlighted the importance of ancillary services, including translators, rideshares, and navigators, in the delivery of care. In addition, whereas hospital stakeholders were aware of collected equity outcomes, they were unsure whether and who is monitoring equity metrics. Furthermore, stakeholders agreed that community outreach showed promise in ensuring equitable access to prostate cancer treatment. Nevertheless, most interviewed stakeholders lacked clear implementation plans.

The effect of limited english proficiency on prostate-specific antigen screening in American men.

PURPOSE: To evaluate how limited English proficiency (LEP) impacts the prevalence of prostate-specific antigen (PSA) screening in a contemporary, nationally representative cohort of men in the USA. METHODS: The Medical Expenditure Panel Survey was utilized to identify the prevalence of PSA screening between 2013 and 2016 among men ≥ 55. Men who speak a language other than English at home were stratified by self-reported levels of English proficiency (men who speak English very well, well, not well, or not at all). Survey weights were applied, and groups were compared using the adjusted Wald test. A multivariable logistic regression model was used to identify predictors of PSA screening adjusting for patient-level covariates. RESULTS: The cohort included 2,889 men, corresponding to a weighted estimate of 4,765,682 men. 79.6% of men who speak English very well reported receiving at least one lifetime PSA test versus 58.4% of men who do not speak English at all (p < 0.001). Men who reported not speaking English at all had significantly lower prevalence of PSA screening (aOR 0.56; 95% CI 0.35-0.91; p = 0.019). Other significant predictors of PSA screening included older age, income > 400% of the federal poverty level, insurance coverage, and healthcare utilization. CONCLUSIONS: Limited English proficiency is associated with significantly lower prevalence of PSA screening among men in the USA. Interventions to mitigate disparities in prostate cancer outcomes should account for limited English proficiency among the barriers to guideline-concordant care.

Smoking characteristics and years since quitting smoking of US adults diagnosed with lung and bladder cancer: A national health and nutrition examination survey analysis.

PURPOSE: Smoking is a recognized risk factor for bladder BC and lung cancer LC. We investigated the enduring risk of BC after smoking cessation using U.S. national survey data. Our analysis focused on comparing characteristics of LC and BC patients, emphasizing smoking status and the latency period from smoking cessation to cancer diagnosis in former smokers. MATERIALS AND METHODS: We analyzed data from the National Health and Examination Survey (2003-2016), identifying adults with LC or BC history. Smoking status (never, active, former) and the interval between quitting smoking and cancer diagnosis for former smokers were assessed. We reported descriptive statistics using frequencies and percentages for categorical variables and median with interquartile ranges (IQR) for continuous variables. RESULTS: Among LC patients, 8.9% never smoked, 18.9% active smokers, and 72.2% former smokers. Former smokers had a median interval of 8 years (IQR 2-12) between quitting and LC diagnosis, with 88.3% quitting within 0-19 years before diagnosis. For BC patients, 26.8% never smoked, 22.4% were active smokers, and 50.8% former smokers. Former smokers had a median interval of 21 years (IQR 14-33) between quitting and BC diagnosis, with 49.3% quitting within 0-19 years before diagnosis. CONCLUSIONS: BC patients exhibit a prolonged latency period between smoking cessation and cancer diagnosis compared to LC patients. Despite smoking status evaluation in microhematuria, current risk stratification models for urothelial cancer do not incorporate it. Our findings emphasize the significance of long-term post-smoking cessation surveillance and advocate for integrating smoking history into future risk stratification guidelines.

Effect of type of definitive treatment on race-based differences in prostate cancer-specific survival.

BACKGROUND: Racial and ethnic disparities in prostate cancer (PCa) mortality are partially mediated by inequities in quality of care. Intermediate- and high-risk PCa can be treated with either surgery or radiation, therefore we designed a study to assess the magnitude of race-based differences in cancer-specific survival between these two treatment modalities. METHODS: Non-Hispanic Black (NHB) and non-Hispanic White (NHW) men with localized intermediate- and high-risk PCa, treated with surgery or radiation between 2004 and 2015 in the Surveillance, Epidemiology and End Results database were included in the study and followed until December 2018. Unadjusted and adjusted survival analyses were employed to compare cancer-specific survival by race and treatment modality. A model with an interaction term between race and treatment was used to assess whether the type of treatment amplified or attenuated the effect of race/ethnicity on prostate cancer-specific mortality (PCSM). RESULTS: 15,178 (20.1%) NHB and 60,225 (79.9%) NHW men were included in the study. NHB men had a higher cumulative incidence of PCSM (p = 0.005) and were significantly more likely to be treated with radiation than NHW men (aOR: 1.89, 95% CI: 1.81-1.97, p < 0.001). In the adjusted models, NHB men were significantly more likely to die from PCa compared with NHW men (aHR: 1.18, 95% CI: 1.03-1.35, p = 0.014), and radiation was associated with a significantly higher odds of PCSM (aHR: 2.10, 95% CI: 1.85-2.38, p < 0.001) compared with surgery. Finally, the interaction between race and treatment on PCSM was not significant, meaning that no race-based differences in PCSM were found within each treatment modality. CONCLUSIONS: NHB men with intermediate- and high-risk PCa had a higher rate of PCSM than NWH men in a large national cancer registry, though NHB and NHW men managed with the same treatment achieved similar PCa survival outcomes. The higher tendency for NHB men to receive radiation was similar in magnitude to the difference in cancer survival between racial and ethnic groups.

Disparate Practice Patterns and Survival Outcomes: The Impact of Centralization of Cancer Care for Adrenocortical Carcinoma in the United States.

PURPOSE: Adrenocortical carcinoma is a rare but aggressive malignancy. While centralization of care to referral centers improves outcomes across common urological malignancies, there exists a paucity of data for low-incidence cancers. We sought to evaluate differences in practice patterns and overall survival in patients with adrenocortical carcinoma across types of treating facilities. MATERIALS AND METHODS: We identified all patients diagnosed with adrenocortical carcinoma from 2004-2016 in the National Cancer Database. The Kaplan-Meier method was used to evaluate overall survival and multivariable Cox regression analysis was used to investigate independent predictors of overall survival. The chi-square test was used to analyze differences in practice patterns. RESULTS: We identified 2,886 patients with adrenocortical carcinoma. Median overall survival was 21.8 months (95% CI 19.8-23.8). Academic centers had improved overall survival versus community centers on unadjusted Kaplan-Meier analysis (p <0.05) and had higher rates of adrenalectomy or radical en bloc resection (p <0.001), performed more open surgery (p <0.001), administered more systemic therapy (p <0.001) and had lower rates of positive surgical margins (p=0.03). On multivariable analysis, controlling for treatment modality, academic centers were associated with significantly decreased risk of death (HR 0.779, 95% CI 0.631-0.963, p=0.021). CONCLUSIONS: Treatment of adrenocortical carcinoma at an academic center is associated with improved overall survival compared to community programs. There are significant differences in practice patterns, including more aggressive surgical treatment at academic facilities, but the survival benefit persists on multivariable analysis controlling for treatment modality. Further studies are needed to identify the most important predictors of survival in this at-risk population.

Patient-Reported Financial Toxicity Associated with Contemporary Treatment for Localized Prostate Cancer.

PURPOSE: Contemporary treatment modalities for localized prostate cancer provide comparable overall and cancer-specific survival. However, the degree of financial burden imposed by treatment, the factors contributing to that burden, and how different treatments compare with regard to financial toxicity remain poorly understood. MATERIALS AND METHODS: The Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) study enrolled men with localized prostate cancer from 2011 to 2012. Questionnaires were collected at 6, 12, 36, and 60 months after enrollment. Differences in patient-reported financial burden were compared between active surveillance, radical prostatectomy, and external beam radiotherapy using multivariable logistic regression. RESULTS: Among 2,121 patients meeting inclusion criteria, 15% reported large or very large burden of treatment costs within 6 months, declining to 3% by year 5. When controlling for age, education, income and other covariates, external beam radiotherapy was associated with greater financial burden than active surveillance and radical prostatectomy at 1 year (OR 2.2, 95% CI 1.2-4.1 and OR 1.5, 95% CI 1.0-2.3, respectively) and 3 years (OR 3.1 95% CI 1.1-8.8 and OR 2.1, 95% CI 1.2-3.7, respectively). Radical prostatectomy and active surveillance had similar rates of financial burden at all time points. Age, race, education, and D'Amico risk group were associated with financial burden. CONCLUSIONS: External beam radiotherapy was associated with the highest financial burden, even when controlling for age, education and income. Prospective studies that directly measure out-of-pocket and indirect costs and account more thoroughly for baseline socioeconomic differences are warranted in order to identify those most at risk.

Urinary pH and the risk of recurrence in patients with non-muscle invasive bladder cancer.

INTRODUCTION: To evaluate the effect of urine pH on tumor recurrence rates in patients undergoing surveillance after initial diagnosis of non-muscle invasive bladder cancer (NMIBC). MATERIALS AND METHODS: All patients diagnosed with NMIBC at a tertiary referral center from January 2004 to March 2015 were reviewed. Our primary outcome was time to first recurrence after transurethral resection of bladder tumor (TURBT). Patients were analyzed according to the average urine pH of all urinalysis data over the surveillance period from TURBT to first recurrence. Kaplan-Meier survival analysis was used to determine differences in median time to recurrence. Cox proportional hazards regression was used to assess independent predictors of cancer recurrence. RESULTS: A total of 252 patients were included, of which 155 patients had average pH ≤ 6 (median pH 5.5) and 97 patients had average pH > 6 (median pH 6.8), p < 0.001. There was no significant difference in median time to recurrence between low/acidic pH (≤ 6) and high/basic pH (> 6) groups (28 months versus 17 months, respectively, p = 0.3444). Similarly, urine pH did not affect the risk of recurrence in a subgroup analysis stratified by smoking status. On multivariable Cox regression analysis, there was no association between average pH and recurrence among high grade tumors (HR = 1.33, 95% CI = 0.76 to 2.34, p = 0.3186), or low grade tumors (HR = 1.013, 95% CI = 1.01 to 1.58, p = 0.96). CONCLUSIONS: There was no association between urine pH and risk of tumor recurrence, regardless of smoking status. These findings suggest that modification of urine pH is unlikely to decrease the frequency of tumor recurrence in patients with NMIBC.

Prognostic Significance of a Negative Prostate Biopsy: An Analysis of Subjects Enrolled in a Prostate Cancer Screening Trial.

PURPOSE: To our knowledge the optimal treatment of patients following a negative prostate biopsy is unknown. Consequently, resources are increasingly being directed toward risk stratification in this cohort. However, the risk of prostate cancer mortality in this group before the introduction of supplemental biomarkers and imaging techniques is unclear. MATERIALS AND METHODS: The PLCO (Prostate, Lung, Colorectal and Ovarian Cancer) Screening Trial provides survival data prior to the implementation of new diagnostic interventions. We divided men with an initial positive screen and a subsequent prostate biopsy into cohorts based on positive or negative results. Prostate cancer specific mortality was then compared to that in the trial control arm to estimate the prognostic significance of biopsy results relative to the general population. RESULTS: A total of 36,525 and 36,560 patients comprised the screening and control arms, respectively. Of 4,064 subjects with a positive first screen 1,233 underwent a linked biopsy, of which 473 were positive and 760 were negative. At a median followup of 12.9 years, 1.1% of men in the negative biopsy cohort had died of prostate cancer. The difference in mortality rates between the negative biopsy and control arms was 0.734 deaths per 1,000 person-years. The proportional subhazard ratios of prostate cancer specific mortality for negative biopsy and positive biopsy relative to the control arm were 2.93 (95% CI 1.44-5.99) and 18.77 (95% CI 12.62-27.93), respectively. CONCLUSIONS: After a negative prostate biopsy, men face a relatively low risk of death from prostate cancer when followed with traditional markers and biopsy techniques. This suggests limited potential for new diagnostic interventions to improve survival in this group.

Robot-assisted partial cystectomy: perioperative outcomes and early oncological efficacy.

OBJECTIVE: To report on patients undergoing robot-assisted partial cystectomy (RAPC), focusing on perioperative outcomes over a range of clinical, anatomical and pathological variables, as well as the overall oncological efficacy of this approach. PATIENTS AND METHODS: We retrospectively reviewed all patients who underwent RAPC by a single surgeon between 2005 and 2015. We identified 29 patients who underwent surgery for definitive management of a primary bladder tumour. Clinicopathological data and perioperative variables were recorded. Continuous variables were compared using the Student's t-test. Prediction of perioperative outcomes for those undergoing RAPC for intra-diverticular neoplasms was done using univariate logistic regression. Survival was estimated using the Kaplan-Meier method. RESULTS: The median (interquartile range) patient age was 75 (65-81) years, 18 patients (62.1%) had an American Society of Anesthesiologists classification of ≥3, and 10 patients (34.5%) had a history of prior abdominal surgery. The median estimated blood loss (EBL) was 50 mL and the median length of stay (LOS) was 1 day. Two patients (6.9%) had a perioperative complication and five (17.9%) a post-discharge complication at ≤90 days, all of which were minor. The positive surgical margin rate was 3.6% and in those with muscle-invasive disease a median of 12 lymph nodes were removed. Neither the size of diverticulum nor the need for ureteric re-implantation was predictive of LOS, EBL, or complication (P > 0.05). We did not encounter any wound, port site, or unusual recurrence patterns to suggest the technical factors of a robotic approach influenced oncological outcomes. The 5-year overall and recurrence-free survival rates were 79% and 68%, respectively. CONCLUSION: RAPC confers the ability to achieve favourable outcomes with low morbidity and reduced hospital stays. Oncological efficacy compares favourably with the published literature. For experienced surgeons, this may represent the optimal surgical approach for organ-preserving bladder surgery.

Prostate size, nocturia and the digital rectal examination: a cohort study of 30 500 men.

OBJECTIVES: To evaluate the utility of the digital rectal examination (DRE) in estimating prostate size and the association of DRE with nocturia in a population-based cohort. SUBJECTS AND METHODS: We identified all men randomized to the screening arm of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO) trial for whom DRE results were available. Men were excluded if they had a history of prostate surgery or incident prostate cancer. Prostate posterior surface area was derived from DRE sagittal and transverse estimates. Relationships between prostate posterior surface area, transrectal ultrasonography (TRUS), prostate-specific antigen (PSA) and nocturia were analysed using intraclass correlation coefficients (ICCs), Spearman's rank correlation and multivariable logistic regression. RESULTS: A total of 30 500 men met the inclusion criteria, with 103 275 screening visits containing paired DRE and PSA data. Digital rectal examination posterior surface area estimates had an ICC of 0.547 (95% CI 0.541-0.554) and were significantly yet modestly correlated with elevated PSA level (rs = 0.18, P < 0.001) and TRUS prostate volume (rs = 0.32, P < 0.001). Prostate posterior surface area was significantly associated with nocturia on multivariable analysis, but was not significant in stratified analysis of men with cardiovascular risk factors (hypertension, diabetes, high body mass index, stroke). In men without these risk factors, the highest quintile of DRE posterior surface area had 22% greater odds of nocturia than the lowest quintile (odds ratio 1.216, 95% CI 1.036-1.427). CONCLUSIONS: Digital rectal examination is a modestly accurate tool for measuring prostate volume. While DRE posterior surface area represents a statistically significant predictor of nocturia, the magnitude of effect suggests it has limited clinical utility for assessing this condition, particularly in the presence of cardiovascular risk factors.

The impact of socioeconomic status on perioperative complications and oncologic outcomes in patients undergoing radical cystectomy.

PURPOSE: To examine if patients of lower socioeconomic status (SES) are at higher risk of perioperative complications and experience different oncologic outcomes after radical cystectomy (RC). METHODS: Retrospective review was performed on 383 consecutive non-metastatic patients who underwent definitive RC at a tertiary referral center. Along with clinical and pathologic parameters traditionally utilized for risk stratification, potential social determinants of health were estimated using US Census data. Zip code-derived proxies of SES included median annual household income and percentage of residents completing high school education. Patients were grouped based on SES parameters, and potential differences were assessed. Multivariable logistic regression was then performed to identify predictors of complication within 90 days of RC. Survival outcomes were plotted using Kaplan-Meier survival curves. RESULTS: Overall, 167 (46.2%) patients suffered any complication within 90 days of RC. On multivariable analysis, length of stay (p ≤ 0.001), lower income grouping (p = 0.03), and lowest education tertile (p = 0.007) were significant predictors of any complication. Income (p = 0.04) and education (p = 0.008) groupings remained significant predictors in a subset analysis looking specifically at post-discharge complications. No significant differences in recurrence-free or overall survival estimates were observed among education (log-rank test: p > 0.9 and p = 0.6, respectively) or income (log-rank test: p = 0.2 and p = 0.09, respectively) groupings. CONCLUSION: Patients of lower socioeconomic status who undergo RC for bladder cancer are at increased risk of perioperative complications. Further studies are needed to clarify this relationship, and to explore interventions aimed to improve outcomes.

Nipple Resection and Reconstruction After Attempted Nipple-Sparing Mastectomy.

BACKGROUND: Occult nipple malignancy is detected in 0% to 58% of attempted nipple-sparing mastectomies (NSM), prompting excision of the nipple. We report our experience with nipple resection following attempted NSM and our outcomes with subsequent nipple reconstruction. METHODS: An institutional review board-approved retrospective review was performed of attempted NSM cases with immediate implant-based reconstruction from July 2006 to April 2015. Patients who underwent nipple excision were identified. Indications for excision, pathology reports, and reconstructive outcomes were reviewed. RESULTS: Five hundred sixty-eight NSMs were performed in 330 patients. Thirty-four (6%) cases underwent nipple excision, 53% for positive frozen sections, 29% for positive permanent sections, 3% for clinical suspicion, and 15% either at patient request or for symmetry. All of the cases with positive frozen sections had disease on permanent section and 56% had residual disease in the resection specimen. Of the cases with positive permanent sections, frozen sections were negative in 50%, suspicious or atypical in 30%, and not sent in 20% of cases. Thirty percent had residual disease in the resection specimen. Frozen section sensitivity was 64% (or 75% if suspicious and atypical findings are included). There were no false-positive results on frozen section. Sixty-eight percent of cases have undergone nipple reconstruction by CV flap (57%), skate flap (39%), or nipple-sharing technique (4%). The aesthetic result after reconstruction was excellent in 83% of cases. CONCLUSIONS: Our findings support the benefit of intraoperative subareolar frozen section for detection of occult disease. When nipple excision is required, patients can still achieve an excellent aesthetic result with reconstruction.

GreenLight laser for prostates over 100 ml: what is the evidence?

PURPOSE OF REVIEW: GreenLight photoselective vaporization of the prostate (PVP) has emerged as a minimally invasive, well tolerated, efficacious alternative to transurethral resection of the prostate (TURP) or simple prostatectomy for the treatment of benign prostatic hyperplasia. However, some authors have expressed concern with the use of PVP in large prostates. In this review, we present the most relevant recent literature regarding PVP for treatment of benign prostatic hyperplasia in prostates over 100 ml. RECENT FINDINGS: Recent studies have found that the subjective and objective outcomes of GreenLight PVP, including International Prostate Symptom Score, quality of lifescore, maximum urinary flow rate, and postvoid residual are comparable in large and small prostates. Though larger glands require increased operative time, energy delivery, and fiber use, the short duration of hospitalization and catheterization does not vary with prostate size. The overall complication rates do not increase with prostate size, though some studies have reported increased conversion to electrocautery TURP hemostasis. The trend toward increased retreatment rates in some studies of PVP in large prostates may be because of inadequate energy density delivered. SUMMARY: GreenLight photoselective PVP is a well tolerated and efficacious procedure regardless of prostate size, and should therefore be considered as a viable alternative to TURP, holmium laser enucleation of the prostate, or simple prostatectomy in large prostates.

Trends in internet search activity, media coverage, and patient-centered health information after the FDA safety communications on surgical mesh for pelvic organ prolapse.

INTRODUCTION: In July 2011, the US Food and Drug Administration (FDA) issued a safety communication regarding serious complications associated with surgical mesh for pelvic organ prolapse, prompting increased media and public attention. This study sought to analyze internet search activity and news article volume after this FDA warning and to evaluate the quality of websites providing patient-centered information. METHODS: Google Trends™ was utilized to evaluate search engine trends for the term "pelvic organ prolapse" and associated terms between 1 January 2004 and 31 December 2014. Google News™ was utilized to quantify the number of news articles annually under the term "pelvic organ prolapse." The search results for the term "pelvic organ prolapse" were assessed for quality using the Health On the Net Foundation (HON) certification. RESULTS: There was a significant increase in search activity from 37.42 in 2010 to 57.75 in 2011, at the time of the FDA communication (p = 0.021). No other annual interval had a statistically significant increase in search activity. The single highest monthly search activity, given the value of 100, was August 2011, immediately following the July 2011 notification, with the next highest value being 98 in July 2011. Linear regression analysis of news articles per year since the FDA communication revealed r2 = 0.88, with a coefficient of 186. Quality assessment demonstrated that 42 % of websites were HON-certified, with .gov sites providing the highest quality information. CONCLUSIONS: Although the 2011 FDA safety communication on surgical mesh was associated with increased public and media attention, the quality of relevant health information on the internet remains of poor quality. Future quality assurance measures may be critical in enabling patients to play active roles in their own healthcare.

The role of acupuncture in managing overactive bladder; a review of the literature.

INTRODUCTION AND HYPOTHESIS: Overactive bladder (OAB) affects a considerable proportion of men and women in the United States and is associated with significant costs and quality of life (QoL) reduction. While medication remains a mainstay of treatment, there is increasing interest in the use of alternative medicine in the form of acupuncture. We reviewed the literature on the role of acupuncture in managing OAB. METHODS: A narrative review was compiled after searching electronic databases (PubMed, MEDLINE, Scopus, and EMBASE) for clinical studies involving acupuncture in treating OAB. Databases were searched from the time of inception through September 2015 by a clinician for articles reporting the results related to the use of acupuncture in OAB. Key search terms were acupuncture, overactive bladder, bladder instability, urgency, urinary incontinence. Articles in English or translated into English were included. RESULTS: Initial animal studies suggest several biochemical mechanisms of action underlying the effect of acupuncture on OAB suppression. The experience in humans includes two case series and six comparative trials. All studies demonstrated subjective improvement in OAB symptoms, and some reported objective improvement in urodynamic studies. Notably, some comparative trials showed the benefit of acupuncture to be comparable with antimuscarinic treatment. CONCLUSION: Despite their limitations, existing studies serve as a promising foundation for suggesting a role for acupuncture as an alternative therapy for OAB. Further well-designed studies are required to investigate optimal technique and their outcomes.