The landscape of biomedical research funding in Brazil: a current overview.

OBJECTIVE: The objective of this narrative review is to discuss the current state of research funding in Brazil. MATERIALS AND METHODS: This study is based on the most recent edition of the course Funding for Research and Innovation in the University of Sao Paulo School of Medicine which was a three-day course with 12 hours of instruction. The course brought together leading experts in the field to comprehensively discuss the current state of research funding in Brazil. Each speaker provided a presentation on a specific topic related to research funding. After the workshop, speakers assembled relevant topics in this manuscript. RESULTS: collaborative research is critical for securing research funding. It optimizes proposal competitiveness, amplifies societal impact, and manages risks effectively. As such, fostering and supporting these collaborations is paramount for both researchers and funding agencies. To maintain the highest integrity in research, investigators involved in these collaborations must disclose any relationships that could potentially influence the outcomes or interpretation of their projects. CONCLUSIONS: In Brazil, the mainstay of research funding stems from public entities, with agencies such as CNPq, CAPES, and state bodies like FAPESP, FAPERJ, FAPEMIG and others at the forefront. Concurrently, industry funding offers viable pathways, especially through industry-sponsored studies, investigator-led projects, and collaborative initiatives. The Brazilian funding landscape is further enriched by innovative platforms, including crowdfunding and the contributions of institutions like the Serrapilheira Institute. Internationally, esteemed organizations such as the National Institutes of Health (NIH) and the Bill & Melinda Gates Foundation stand out as potential funders.

Effects of the addition of quantitative apparent diffusion coefficient data on the diagnostic performance of the PI-RADS v2 scoring system to detect clinically significant prostate cancer.

PURPOSE: To evaluate the impact of the addition of quantitative apparent diffusion coefficient (ADC) data into the diagnostic performance of the Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) scoring system to predict clinically significant prostate cancer (CSPCa). METHODS: We retrospectively included 91 consecutive patients who underwent prostate multiparametric magnetic resonance imaging (mp-MRI) and histopathological evaluation. Mp-MRI images were reported by the PI-RADSv2 scoring system and patients were divided into groups considering the likelihood of CSPCa. ADC value and ratio were obtained. Findings were correlated with histopathological data. RESULTS: CSPCa was found in 41.8% of cases (n = 38). PI-RADSv2 score 3-5 yielded a sensitivity of 97.4% (95% confidence intervals 86.5-99.5), a specificity of 50.9% (37.9-63.9), and AUC of 0.74 (0.67-0.81) to predict CSPCa. ADC value < 750 µm2/s and an ADC ratio < 0.62 were the most accurate thresholds for differentiation of CSPCa, with AUC of 0.81 and 0.76, respectively. Combined PI-RADSv2 score 3-5 and ADC value < 750 µm2/s yielded a specificity of 84.9 (72.9-92.2), sensitivity of 70.3 (54.2-82.5), and AUC of 0.77 (0.68-0.86). Combined PI-RADSv2 score 3-5 and ADC ratio < 0.62 yielded a specificity of 86.5 (74.7-93.3), sensitivity of was 64.9 (48.8-78.2), and AUC of 0.75 (0.66-0.84). CONCLUSION: Quantitative ADC data might not be beneficial to be used routinely in mp-MR imaging as criteria to detect clinically significant lesions due to the reduced sensitivity. Instead, when prostate lesions present a PI-RADSv2 score ≥ 3, additional quantitative ADC criteria can be helpful to increase the PI-RADS score specificity.

Small renal masses in Latin-American population: characteristics and prognostic factors for survival, recurrence and metastasis - a multi-institutional study from LARCG database.

BACKGROUND: To evaluate demographic, clinical and pathological characteristics of small renal masses (SRM) (≤ 4 cm) in a Latin-American population provided by LARCG (Latin-American Renal Cancer Group) and analyze predictors of survival, recurrence and metastasis. METHODS: A multi-institutional retrospective cohort study of 1523 patients submitted to surgical treatment for non-metastatic SRM from 1979 to 2016. Comparisons between radical (RN) or partial nephrectomy (PN) and young or elderly patients were performed. Kaplan-Meier curves and log-rank tests estimated 10-year overall survival. Predictors of local recurrence or metastasis were analyzed by a multivariable logistic regression model. RESULTS: PN and RN were performed in 897 (66%) and 461 (34%) patients. A proportional increase of PN cases from 48.5% (1979-2009) to 75% (after 2009) was evidenced. Stratifying by age, elderly patients (≥ 65 years) had better 10-year OS rates when submitted to PN (83.5%), than RN (54.5%), p = 0.044. This disparity was not evidenced in younger patients. On multivariable model, bilaterality, extracapsular extension and ASA (American Society of Anesthesiologists) classification ≥3 were predictors of local recurrence. We did not identify significant predictors for distant metastasis in our series. CONCLUSIONS: PN is performed in Latin-America in a similar proportion to developed areas and it has been increasing in the last years. Even in elderly individuals, if good functional status, sufficiently fit to surgery, and favorable tumor characteristics, they should be encouraged to perform PN. Intending to an earlier diagnosis of recurrence or distant metastasis, SRM cases with unfavorable characteristics should have a more rigorous follow-up routine.

Characteristics and Surgical Outcomes in Very Elderly Patients (≥75 years) with Renal Cell Carcinoma: Data from the Latin American Renal Cancer Group.

BACKGROUND: The incidence of renal cell carcinoma (RCC) is increasing globally due to an aging population and widespread use of imaging studies. OBJECTIVE: The aim of this study was to describe the characteristics and perioperative outcomes of RCC surgery in very elderly patients (VEP), ≥ 75 years of age. METHODS: This is a retrospective comparative study of 3656 patients who underwent the treatment for RCC from 1990 to 2015 in 28 centers from eight Latin American countries. We compared baseline characteristics as well as clinical and perioperative outcomes according to age groups (less than 75 vs. ≥75 years). Surgical complications were classified with the Clavien-Dindo score. We performed logistic regression analysis to identify factors associated with perioperative complications. RESULTS: There were 410 VEP patients (11.2%). On bivariate analysis, VEP had a lower body mass index (p less than 0.01) and higher ASA score (ASA > 2 in 26.3% vs. 12.4%, p < 0.01). There was no difference in performance status and clinical stage between the study groups. There were no differences in surgical margins, estimated blood loss (EBL), complication, and mortality rates (1.3% vs. 0.4%, p = 0.17). On multivariate regression analysis, age ≥75 years (odds ratio [OR] 2.33, p less than 0.01), EBL ≥ 500 cc (OR 3.34, p less than 0.01), and > pT2 stage (OR 1.63, p = 0.04) were independently associated with perioperative complications. CONCLUSIONS: Surgical resection of RCC was safe and successful in VEP. Age ≥75 years was independently associated with 30-day perioperative complications. However, the vast majority were low-grade complications. Age alone should not guide decision-making in these patients, and treatment must be tailored according to performance status and severity of comorbidities.

Second brazilian consensus on the treatment of advanced prostate cancer - a SBOC-SBU-SBRT panel review.

Prostate cancer is the second most common cancer and the fi fth leading cause of cancer deaths. In Brazil, it is likewise the second most common cancer among men, second only to non-melanoma skin cancers. The aim of this consensus is to align different opinions and interpretations of the medical literature in a practical and patient-oriented approach. The fi rst Brazilian Consensus on the Treatment of Advanced Prostate Cancer was published in 2017, with the goal of reducing the heterogeneity of therapeutic conduct in Brazilian patients with metastatic prostate cancer. We acknowledge that in Brazil the incorporation of different technologies is a big challenge, especially in the Sistema Único de Saúde (SUS), which allows for the disparity in the options available to patients treated in different institutions. In order to update the recommendations and to make them objective and easily accessible, once more a panel of specialists was formed in order to discuss and elaborate a new Brazilian Consensus on Advanced Prostate Cancer. This Consensus was written through a joint initiative of the Brazilian Society of Clinical Oncology (SBOC) and the Brazilian Society of Urology (SBU) to support the clinical decisions of physicians and other health professionals involved in the care of patients with prostate cancer.

Serum tissue factor as a biomarker for renal clear cell carcinoma.

PURPOSE: to determine the usefulness of serum TF as a potential marker for patients with clear cell RCC. MATERIALS AND METHODS: prospective study of 30 patients with clear cell RCC submitted to nephrectomy and 16 controls without clear cell RCC treated surgically for other conditions. TF is a endothelium marker that was correlated with worse prognosis in a variety of solid tumors including RCC. Serum TF was collected before surgery at the operating room and in the postoperative setting after at least four weeks. Serum samples were analyzed with a commercial ELISA kit for human TF (R&D Systems®). RESULTS: Mean preoperative serum TF levels in clear cell RCC patients and in controls were 66.8 pg/dL and 28.4 pg/dL, respectively (p<0.001). Mean postoperative serum TF levels in clear cell RCC patients were 26.3 pg/dL. In all patients with clear cell RCC postoperative serum levels of TF were lower, with a mean reduction of 41.6 pg/dL in the postoperative setting (p<0.001). Linear regression revealed that tumor size was correlated with the postoperative reduction of serum TF levels (p=0.037). CONCLUSIONS: We have shown a 3-fold reduction in the median preoperative serum levels of TF in patients with clear cell RCC after surgery. We have also shown a difference of the same magnitude in the serum levels of TF compared with those of a control group of patients with benign diseases. TF appears to be a useful serum marker for the presence of clear cell RCC. Further studies are needed to validate these findings.

Gastric neobladders: surgical outcomes of 91 cases using different techniques.

INTRODUCTION: We report on the surgical results of a series of 91 patients who received gastric neobladders as urinary diversion after radical cystectomies performed for the treatment of muscle-invasive bladder cancers. MATERIALS AND METHODS: We report on a retrospective case series of 91 patients who received gastric neobladders as urinary diversion after radical cystectomies performed for the treatment of muscle-invasive bladder cancers. Different techniques of gastric neobladders were employed from 1988 to 2013 at a university hospital in the South of Brazil. RESULTS: Initial outcomes utilizing Leong (Antral) and Nguyen-Mitchell (Wedge) technique were unsatisfactory, yielding high pressure, low capacity reservoirs. Further developments of these techniques, with the detubularized gastric neobladder and the "spherical" gastric neobladders resulted in low pressure, high capacity reservoirs, with better surgical and urodynamic outcomes. Complication and perioperative mortality rates of our series of gastric neobladders were significantly higher than historical results of techniques using ileum or colon. CONCLUSIONS: Stomach is an exceptional option for the creation of neobladders after radical cystectomies, but due to the increased complication rates it should be reserved for specific situations (e.g., renal insufficiency, previous pelvic/abdominal radiotherapy, short bowel syndromes).

First Brazilian Consensus of Advanced Prostate Cancer: Recommendations for Clinical Practice.

INTRODUCTION: Prostate cancer still represents a major cause of morbidity, and still about 20% of men with the disease are diagnosed or will progress to the advanced stage without the possibility of curative treatment. Despite the recent advances in scientific and technological knowledge and the availability of new therapies, there is still considerable heterogeneity in the therapeutic approaches for metastatic prostate cancer. OBJECTIVES: This article presents a summary of the I Brazilian Consensus on Advanced Prostate Cancer, conducted by the Brazilian Society of Urology and Brazilian Society of Clinical Oncology. MATERIALS AND METHODS: Experts were selected by the medical societies involved. Forty issues regarding controversial issues in advanced disease were previously elaborated. The panel met for consensus, with a threshold established for 2/3 of the participants. RESULTS AND CONCLUSIONS: The treatment of advanced prostate cancer is complex, due to the existence of a large number of therapies, with different response profiles and toxicities. The panel addressed recommendations on preferred choice of therapies, indicators that would justify their change, and indicated some strategies for better sequencing of treatment in order to maximize the potential for disease control with the available therapeutic arsenal. The lack of consensus on some topics clearly indicates the absence of strong evidence for some decisions.

Validation of PI-RADS v.2 for prostate cancer diagnosis with MRI at 3T using an external phased-array coil.

PURPOSE: To date, few studies have validated the Prostate Imaging Reporting and Data System Version 2 (PI-RADS v. 2) for the diagnosis of prostate cancer. Our aim was to validate PI-RADS v.2 using 3 Tesla (T) MRI. MATERIALS AND METHODS: This is a retrospective study of 54 consecutive patients who underwent 3T MRI with a body-array coil for diagnostic confirmation of prostate cancer or cancer staging between June 2013 and June 2015. Sensitivity, specificity, and agreement were calculated based on a criterion of PI-RADS score = 3. Inter-examiner agreement was determined by the weighted kappa statistic. RESULTS: Histological findings were positive for cancer in 33 patients and negative in 21 patients. Considering a PI-RADS score of 3 as positive for cancer, the accuracy of each reader was 85.20% and 70.40%, respectively, and agreement coefficients were κ = 0.69 and κ = 0.35. Considering PI-RADS 3 as absence of cancer, the accuracy of each reader was 77.80% and 77.80%, respectively, and agreement was κ = 0.55 and κ = 0.54. Inter-reader agreement was moderate/good (weighted κ = 0.53; 95% confidence interval: 0.39-0.66; P = 0.038). CONCLUSION: High accuracy was obtained for the diagnosis of prostate cancer using 3T MRI with a body coil and the PI-RADS v.2 score. J. Magn. Reson. Imaging 2016;44:1354-1359.

Increased tissue factor expression is an independent predictor of mortality in clear cell carcinoma of the kidney.

PURPOSE: Increased expression of tissue factor (TF), a primary initiator of the extrinsic coagulation pathway, has been associated with a worse prognosis in a variety of solid tumors. We report for the first time the correlation of the immunohistochemical expression of tissue factor with clinical and pathological outcomes in clear cell carcinomas of the kidney. MATERIALS AND METHODS: immunohistochemical expression of tissue factor was evaluated in 58 paraffin-embedded samples of clear cell carcinomas of the kidney treated at the same university hospital, that was correlated with clinical and pathological variables and with overall survival. RESULTS: high intensity tissue factor expression (TF area > 10 µ m2) was observed in 22.4% of the tumors (13 patients), and was an important predictor of overall mortality, both in univariate and multivariate analysis (p < 0.05). Median overall survival for both groups was 66 months; 78.2 months for patients in the group of lower TF expression and 27.5 months for patients in the group of higher TF expression (log rank p < 0.001). The hazard ratio for mortality was 9.7 (CI 3.7-25.6) for tumors with increased TF expression. CONCLUSIONS: Increased immunohistochemical expression of TF was an important independent predictor of mortality in a contemporary cohort of patients with clear cell carcinoma of the kidney. Further studies are necessary to define the role of TF in clinical practice.

Association between family history of prostate cancer and positive biopsies in a Brazilian screening program.

PURPOSE: To test the association between family history of prostate cancer (FH) and prostate cancer (PCa) risk in a large screening program in Brazil, as no conclusive study has yet investigated this. METHODS: Between 2004 and 2007, 17,569 men were screened in 231 small municipalities using mobile screening units. Positive FH was defined as any relative having PCa among screened men. Men were biopsied if they had digital rectal examination suggestive of PCa or PSA >4.0 ng/mL or PSA of 2.5-4 ng/mL with percent free PSA ≤ 15 %. We analyzed the association between FH and PCa using multivariable logistic regression in the first screening round of the program. RESULTS: Positive FH was present in 735 men (4.2 % of total), and they were younger, better educated and more likely to have had previous PCa screening (41.5 vs. 28.5 %; P < 0.001) compared to men with negative FH. FH status did not affect compliance rates in men recommended to undergo biopsy (P = 0.94). In first round, PCa was detected in 3.1 % of screened men (n = 552). In multivariable analysis, positive FH was associated with increased PCa risk (OR = 1.79; 95 % CI, 1.21-2.65; P = 0.003). However, Gleason scores (P = 0.78) or percent of positive cores (P = 0.32) among men with positive biopsies were similar, regardless of FH status. CONCLUSIONS: In Brazil, men with positive FH were at increased PCa risk, which could not be explained by differential biopsy rates. This finding suggests that FH is also a true PCa risk factor in Brazil, a country with highly diverse population in terms of race, ethnicity, culture and socioeconomic status.

Association between literacy, compliance with prostate cancer screening, and cancer aggressiveness: results from a Brazilian screening study.

PURPOSE: Little is known about the effects of literacy levels on prostate cancer screening. This study evaluates the association between literacy, compliance with screening, and biopsy findings in a large Brazilian screening study. MATERIALS AND METHODS: We analyzed 17,571 men screened for PCa with digital rectal examination (DRE) and total and free prostate-specific antigen (PSA) from January 2004 to December 2007. Of those, 17,558 men had information regarding literate status. Full urological evaluation in a specialized cancer center was recommended in the case of: a) suspicious DRE, b) PSA > 4.0 ng/mL, or c) PSA 2.5-3.9 ng/mL and free/total PSA (f/tPSA) ratio 15%. Transrectal ultrasound guided prostate biopsy (14 cores) was performed upon confirmation of these findings after the patient's consent. Patients' compliance with screening recommendations and biopsy results were evaluated according to literacy levels. RESULTS: an abnormal PSA, a suspicious DRE, or both were present in 73.2%, 19.7%, and 7.1% of those men who underwent biopsy, respectively. PCa was diagnosed in 652 men (3.7%). Previous PSAs or DREs were less common among illiterate men (p < 0.0001). Additionally, illiterate men were less prone to attend to further evaluations due to an abnormal PSA or DRE (p < 0.0001). PSA levels > 10 mg/mL (p = 0.03), clinical stage > T2a (p = 0.005), and biopsy Gleason > 7 (p = 0.02) were more common among illiterate men. CONCLUSIONS: In a screened population, literacy levels were associated with prior PCa evaluations and with compliance with screening protocols. Illiterate men were at higher risk of being diagnosed with more advanced and aggressive PCa.

"Non-metastatic, Castration-resistant Prostate Cancer: Diagnostic and Treatment Recommendations by an Expert Panel from Brazil".

INTRODUCTION: Non-metastatic, castration-resistant prostate cancer (nmCRPC) is an important clinical stage of prostate cancer, prior to morbidity and mortality from clinical metastases. In particular, the introduction of novel androgen-receptor signaling inhibitors (ARSi) has changed the therapeutic landscape in nmCRPC. Given recent developments in this field, we update our recommendations for the management of nmCRPC. METHODS: A panel of 51 invited medical oncologists and urologists convened in May of 2021 with the aim of discussing and providing recommendations regarding the most relevant issues concerning staging methods, antineoplastic therapy, osteoclast-targeted therapy, and patient follow-up in nmCRPC. Panel members considered the available evidence and their practical experience to address the 73 multiple-choice questions presented. RESULTS: Key recommendations and findings include the reliance on prostate-specific antigen doubling time for treatment decisions, the absence of a clear preference between conventional and novel (i.e., positron-emission tomography-based) imaging techniques, the increasing role of ARSis in various settings, the general view that ARSis have similar efficacy. Panelists highlighted the slight preference for darolutamide, when safety is of greater concern, and a continued need to develop high-level evidence to guide the intensity of follow-up in this subset of prostate cancer. DISCUSSION: Despite the limitations associated with a consensus panel, the topics addressed are relevant in current practice, and the recommendations can help practicing clinicians to provide state-of-the-art treatment to patients with nmCRPC in Brazil and other countries with similar healthcare settings.

Use of low free to total PSA ratio in prostate cancer screening: detection rates, clinical and pathological findings in Brazilian men with serum PSA levels <4.0 ng/mL.

UNLABELLED: What's known on the subject? and What does the study add? In spite of its low specificity, PSA is the most widely used screening test for prostate cancer (PCa), and is considered the main cause of the stage migration recently observed. The ratio of free to total PSA (%fPSA) has been shown to increase PSA accuracy in cancer detection; however, few screening studies have systematically evaluated its role in cancer detection rates in men with PSA levels <4.0 ng/mL and normal DRE. The present study supports a possible role of %fPSA as an adjunct to screening in men with total PSA 2.5-4.0 ng/mL and normal DRE, with a marked increase in cancer detection rates in a large Brazilian PCa screening study. We believe that %fPSA maybe a useful refinement to biopsy indications in men with low PSA levels. OBJECTIVE: • To evaluate the role of the free to total prostate-specific antigen ratio (%fPSA) in identifying prostate cancer (PCa) in men with a prostate-specific antigen (PSA) level of 2.5-3.9 ng/mL and a normal digital rectal examination (DRE). PATIENTS AND METHODS: • A prospective PCa screening study was conducted, which included 17571 men aged ≥ 45 years, across six Brazilian states, where men were recalled for further evaluation in the case of either a suspicious DRE and/or PSA ≥ 4.0 ng/mL, or PSA 2.5-3.9 ng/mL and %fPSA ≤ 15. • We evaluated the impact of a %fPSA ≤ 15 on cancer detection rates and the clinical and pathological stage of tumours in men with a normal DRE and PSA 2.5-3.9 ng/mL. RESULTS: • When suspicious DRE and/or PSA ≥ 4.0 ng/mL were considered as criteria to prompt further evaluation, the cancer detection rate was 3.1%. When %fPSA ≤ 15 in men with total PSA levels of 2.5-3.9 ng/mL were considered as criteria, the PCa detection rate increased to 3.7%. Considering %fPSA ≤ 15 in men with PSA 2.5-3.9 ng/mL and normal DRE, the positive predictive value of biopsy was 31.1%. • Clinical stage was more favourable among men with PSA 2.5-3.9 ng/mL, normal DRE, and %fPSA ≤ 15 compared with men with normal DRE and PSA ≥ 4.0 ng/mL (P= 0.02). • Among those who underwent radical prostatectomy, pathological stage and the proportion of insignificant tumours were similar between men with PSA 2.5-3.9 ng/mL, normal DRE findings and %fPSA ≤ 15, and men with PSA ≥ 4.0 ng/mL. CONCLUSIONS: • The use of %fPSA ≤ 15 as a biopsy indication in men with normal DRE and PSA 2.5-4.0 ng/mL in a PCa screening programme, increased cancer detection rates. Tumours in this subset of patients had similar pathological characteristics. • Using %fPSA ≤ 15 to indicate biopsy in men with PSA 2.5-3.9 ng/mL is a useful adjunct to PCa screening.

The impact of preoperative immune checkpoint inhibitors on kidney and bladder cancer surgeries: a systematic review☆.

Therapies based on the use of immune checkpoint inhibitors (ICIs), such as nivolumab, pembrolizumab, ipilimumab, atezolizumab, avelumab, and durvalumab, have proven effective in the treatment of metastatic urological neoplasms. Recently, it has been hypothesized that the use of this type of treatment prior to surgery could lead to an increased difficulty in renal and bladder surgeries. The literature concerning this topic, however, is still scarce and non-consensual. In our systematic review, we used the PRISMA guidelines methodology to search the pertinent literature available up to June 18, 2020 in PubMed. Additionally, we searched the related grey literature in the abstracts of the meetings of the American Society of Clinical Oncology (ASCO), American Society of Clinical Oncology Genitourinary (ASCO-GU), European Society of Medical Oncology (ESMO), and American Urological Association (AUA) from 2015 to 2020. We were able to find only 16 publications that addressed the use of ICIs prior to surgery in kidney and bladder neoplasms. The results were conflicting, and usually the issue of surgical difficulties after the use of ICIs was not directly approached. We hope that our publication may raise the awareness towards the need to further investigate the effects of neoadjuvant ICIs on surgical outcomes in urologic cancers.

Delay of surgery in men with low risk prostate cancer.

PURPOSE: Treatment options for patients with low risk prostate cancer include radical prostatectomy, radiation therapy, and active surveillance. Among patients treated with radical prostatectomy, prior studies have demonstrated significantly higher biochemical progression rates with surgical delays of 6 months or greater. We determined the impact of surgical delay on radical prostatectomy outcomes specifically in low risk patients. MATERIALS AND METHODS: From our radical prostatectomy database we identified men who fulfilled the D'Amico low risk criteria (clinical stage T1c/T2a, prostate specific antigen less than 10 ng/ml, and biopsy Gleason 6 or less). Pathological tumor features and biochemical progression rates were compared between men with and without surgical delay. We used Cox proportional hazards models to examine predictors of biochemical progression. RESULTS: Of 1,111 men who fulfilled the D'Amico low risk criteria, those with a surgical delay of 6 months or more were significantly older, had a higher proportion of African American men, and a lower proportion of clinical stage T2a (vs T1). A surgical delay of 6 months or more was associated with a greater risk of high grade disease at prostatectomy (p = 0.001) and biochemical progression (p = 0.04). The progression-free survival rate was significantly lower among men with a surgical delay. On multivariate analysis with prostate specific antigen and clinical stage, surgical delays of 6 months or more were significantly and independently associated with time to biochemical progression. CONCLUSIONS: In men who met the D'Amico low risk criteria, a surgical delay of 6 months or more was associated with significantly worse radical prostatectomy outcomes, including more pathology upgrading and a higher rate of biochemical progression. Low risk patients choosing to defer initial definitive therapy should be counseled regarding the possibility of worse treatment outcomes at a later date.

Implications of Regionalizing Care in the Developing World: Impact of Distance to Referral Center on Compliance to Biopsy Recommendations in a Brazilian Prostate Cancer Screening Cohort.

Given growing specialization in medical care, optimal care may require regionalization, which may create access barriers. We tested this within a large prostate cancer (PC) screening program in Brazil. In 2004-2007, Barretos Cancer Hospital prospectively screened men for PC throughout rural Brazil. Men with abnormal screen were referred for follow-up and possible biopsy. We tested the link between distance from screening site to Barretos Cancer Hospital and risk of noncompliance with showing up for biopsy, PC on biopsy and, among those with PC, PC grade using crude and multivariable logistic regression analysis. Among 10,467 men undergoing initial screen, median distance was 257 km (IQR: 135-718 km). On crude and multivariable analyses, farther distance was significantly linked with biopsy noncompliance (OR/100 km: 0.83, P < 0.001). Among men who lived within 150 km of Barretos Cancer Hospital, distance was unrelated to compliance (OR/100 km: 1.09, P=0.87). There was no association between distance and PC risk or PC grade (all P > 0.25). In Brazil, where distances to referral centers can be large, greater distance was related to reduced biopsy compliance in a PC screening cohort. Among men who lived within 150 km, distance was unrelated to compliance. Care regionalization may reduce access when distances are large.

Recommendations on robotic-assisted radical prostatectomy: a Brazilian experts' consensus.

Radical prostatectomy is a commonly adopted treatment for localized/locally advanced prostate cancer in men with a life expectancy of ten years or more. Robotic-assisted radical prostatectomy (RARP) is comparable to open radical prostatectomy on cancer control and complication rates; however, new evidence suggests that RARP may have better functional outcomes, especially with respect to urinary incontinence and erectile dysfunction. Some of the surgical steps of RARP are not adequately described in published literature and, as such, may have an impact on the final outcomes of the procedure. We organized a Brazilian experts' panel to evaluate best practices in RARP. The confection of the recommendations broadly involved: selection of the experts; establishment of working groups; systematic review of the literature and elaboration of a questionnaire; and construction of the final text with the approval of all participants. The participants reviewed the publications in English from December 2019 to February 2020. A one-round Delphi technique was employed in 188 questions. Five reviewers worked on the final recommendations using consensual and non-consensual questions. We found 59.9% of questions with greater than 70% agreement that were considered consensual. Non-consensual questions were reported according to the responses. The recommendations were based on evidence-based literature and individual perceptions adapted to the Brazilian reality, although some issues remain controversial. We believe that these recommendations may help urologists involved in RARP and hope that future discussions on this surgical procedure may evolve over the ensuing years.

Prognostic Factors in De Novo Metastatic Renal Cell Carcinoma: A Report From the Latin American Renal Cancer Group.

PURPOSE: To assess the effect of clinical and pathological variables on cancer-specific and overall survival (OS) in de novo metastatic patients from a collaborative of primarily Latin American countries. PATIENTS AND METHODS: Of 4,060 patients with renal cell carcinoma diagnosed between 1990 and 2015, a total of 530 (14.5%) had metastasis at clinical presentation. Relationships between clinical and pathological parameters and treatment-related outcomes were analyzed by Cox regression and the log-rank method. RESULTS: Of 530 patients, 184 (90.6%) had died of renal cell carcinoma. The median OS of the entire cohort was 24 months. American Society of Anesthesiology classification 3-4 (hazard ratio [HR]: 1.64), perirenal fat invasion (HR: 2.02), and ≥ 2 metastatic organ sites (HR: 2.19) were independent prognostic factors for 5-year OS in multivariable analyses. We created a risk group stratification with these variables: no adverse risk factors (favorable group), median OS not reached; one adverse factor (intermediate group), median OS 33 months (HR: 2.04); and two or three adverse factors (poor risk group), median OS 14 months (HR: 3.58). CONCLUSION: Our study defines novel prognostic factors that are relevant to a Latin American cohort. With external validation, these easily discerned clinical variables can be used to offer prognostic information across low- and middle-income countries.

Treatment of Localized and Locally Advanced, High-Risk Prostate Cancer: A Report From the First Prostate Cancer Consensus Conference for Developing Countries.

PURPOSE: To generate and present survey results on important issues relevant to treatment and follow-up of localized and locally advanced, high-risk prostate cancer (PCa) focusing on developing countries. METHODS: A panel of 99 PCa experts developed more than 300 survey questions of which 67 questions concern the main areas of interest of this article: treatment and follow-up of localized and locally advanced, high-risk PCa in developing countries. A larger panel of 99 international multidisciplinary cancer experts voted on these questions to create the recommendations for treatment and follow-up of localized and locally advanced, high-risk PCa in areas of limited resources discussed in this article. RESULTS: The panel voted publicly but anonymously on the predefined questions. Each question was deemed consensus if 75% or more of the full panel had selected a particular answer. These answers are based on panelist opinion and not on a literature review or meta-analysis. For questions that refer to an area of limited resources, the recommendations considered cost-effectiveness as well as the possible therapies with easier and greater access. Each question had five to seven relevant answers including two nonanswers. Results were tabulated in real time. CONCLUSION: The voting results and recommendations presented in this article can guide physicians managing localized and locally advanced, high-risk PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for treatment of localized and locally advanced, high-risk PCa in developing countries have not been defined, this article will serve as a point of reference when confronted with this disease.