Biochemical recurrence after radical prostatectomy - a large, comprehensive, population-based study with long follow-up.

OBJECTIVE: We evaluated long-term risk for biochemical recurrence and subsequent prognosis in a population-based cohort. MATERIAL AND METHODS: We used register-based data to evaluate 6 675 consecutive patients having radical prostatectomy in Västra Götaland county in Sweden during 1995-2014. Patients were followed until death or end of study, 31 December 2014. Data were collected from registers on national, regional and local level and linked by means of the Swedish personal identity number. Biochemical recurrence was defined as PSA ≥0.2 ng/ml; failure as hormonal treatment, metastasis or prostate cancer death. Survival analysis was used to estimate time to biochemical recurrence and time to failure after biochemical recurrence for patients with 0 - 2 years, 2-5 years, 5-10 years and >10 years interval to biochemical recurrence, respectively. RESULTS: A total of 1214 men had biochemical recurrence during follow-up. Biochemical recurrence-free survival was 83% (95% confidence interval [CI] 82-84%), 75% (95% CI 74-77%) and 69% (95% CI 67-71%) at 5, 10 and 15 years, respectively. Cumulative incidence of failure for all patients 15 years after biochemical recurrence was 50% (95% CI 43-55%) in competing risk analysis. The risk of failure after biochemical recurrence was highest among patients having biochemical recurrence within 2 years from surgery. Incomplete data on PSA-history is a limitation. CONCLUSIONS: The risk for biochemical recurrence persists 15 years after surgery. Follow-up should continue as long as treatment would be considered in case of recurrent disease.

Changes in Characteristics of Men with Lethal Prostate Cancer During the Past 25 Years: Description of Population-based Deaths.

Background: Attempts to reduce prostate cancer (PC) mortality require an understanding of temporal changes in the characteristics of men with lethal PC. Objective: To describe the diagnostic characteristics of and time trends for a nationwide population-based cohort of Swedish men who died from PC between 1992 and 2016. Design setting and participants: Men with PC as the underlying cause of death from 1992 to 2016 according to the Swedish Cause of Death Register were included in the study. Characteristics at diagnosis were collected via links to other nationwide registries using personal identity numbers. Outcome measurements and statistical analysis: Data on disease duration, age at death, and risk category were analyzed. Missing data for risk categories for men with an early date of PC diagnosis were imputed according to the method of chained equations. Results and limitations: Between 1992 and 2016, age-standardized PC mortality decreased by 25%. Median PC disease duration increased from 3.3 yr (interquartile range [IQR] 1.6-6.3) to 5.9 yr (IQR 2.5-10.3) and the median age at death from PC increased from 78.9 yr (IQR 73.3-84.2) to 82.2 yr (IQR 75.2-87.5). The proportion of men with localized disease at diagnosis who died from PC increased from 34% to 48%, while the rate of distant metastases at diagnosis decreased from 56% to 42%. The rate of distant metastases at diagnosis was highest among the youngest men. Treatment trajectories could not be described owing to the large proportion of missing data before the start of registration in the National Prostate Cancer Registry. Conclusion: Age-standardized PC mortality has decreased substantially since 1992. However, there is still a high proportion of men who die from PC who had localized disease at diagnosis, which indicates that more attention is needed to identify the underlying causes to prevent disease progression. Since the proportion of men with distant metastases at diagnosis remains high, early detection of lethal tumors is essential to further reduce PC mortality. Patient summary: We investigated the characteristics of men who died from prostate cancer in Sweden between 1992 and 2016. We found that men with lethal prostate cancer live longer and are older when they die today in comparison to men who died at the beginning of the study period. However, the proportion of men with distant metastases at diagnosis remains high, which is why early detection of lethal tumors is essential to reduce mortality.

Degree of Preservation of Neurovascular Bundles in Radical Prostatectomy and Recurrence of Prostate Cancer.

BACKGROUND: Reports on possible benefits for continence with nerve-sparing (NS) radical prostatectomy have expanded the indications beyond preservation of erectile function. It is unclear whether NS surgery affects oncological outcomes. OBJECTIVE: To determine whether the degree of NS during radical prostatectomy influences oncological outcomes. DESIGN SETTING AND PARTICIPANTS: Of 4003 patients enrolled in a prospective, controlled trial comparing open and robotic radical prostatectomy during 2008-2011, we evaluated 2401 patients who received robotic radical prostatectomy at seven Swedish centres. Patients were followed for 8 yr. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Data for recurrence and positive surgical margin status were assessed using validated patient questionnaires, patient interviews, and clinical record forms before and at 3, 12, and 24 mo and 6 and 8 yr after surgery. Cox and logistic regressions were used to model the effect on recurrence and positive surgical margins (PSM), respectively. RESULTS AND LIMITATIONS: A total of 481 men had PSM and 467 experienced recurrence during follow-up. Median follow-up for men without recurrence was 6.6 yr. There were no statistically significant differences in recurrence rate between degrees of NS. The PSM rate was significantly higher with a higher degree of NS: interfascial NS, odds ratio (OR) 2.32 (95% confidence interval [CI] 1.69-3.16); intrafascial NS, OR 3.23 (95% CI 2.17-4.80). Recurrence rates were higher for patients with pT2 disease and PSM (hazard ratio [HR] 3.32, 95% CI 2.43-4.53) than for patients with pT3 disease without PSM (HR 2.08, 95% CI 1.66-2.62). The lack of central review of pathological specimens is a limitation. CONCLUSIONS: A higher degree of NS significantly increased the risk of PSM but did not significantly increase the risk of cancer recurrence. Combined with the known functional benefits of NS surgery, these results underscore the need to identify an individualised balance. PATIENT SUMMARY: In this report we looked at the effect of a nerve-sparing approach during removal of the prostate on cancer outcomes for patients having robot-assisted surgery at seven Swedish hospitals. We found that a high degree of nerve-sparing increased the rate of cancer positivity at the margins of surgical specimens and that positive surgical margins increased the risk of recurrence of prostate cancer.

Preparedness for side effects and bother in symptomatic men after radical prostatectomy in a prospective, non-randomized trial, LAPPRO.

BACKGROUND: Many clinicians believe that preparedness before surgery for possible post-surgery side effects reduces the level of bother experienced from urinary incontinence and decreased sexual health after surgery. There are no published studies evaluating this belief. Therefore, we aimed to study the level of preparedness before radical prostatectomy and the level of bother experienced from urinary incontinence and decreased sexual health after surgery. MATERIAL AND METHODS: We prospectively collected data from a non-selected group of men undergoing radical prostatectomy in 14 centers between 2008 and 2011. Before surgery, we asked about preparedness for surgery-induced urinary problems and decreased sexual health. One year after surgery, we asked about bother caused by urinary incontinence and erectile dysfunction. As a measure of the association between preparedness and bothersomeness we modeled odds ratios (ORs) by means of logistic regression. RESULTS: Altogether 1372 men had urinary incontinence one year after surgery as well as had no urinary leakage or a small urinary dribble before surgery. Among these men, low preparedness was associated with bother resulting from urinary incontinence [OR 2.84; 95% confidence interval (CI) 1.59-5.10]. In a separate analysis of 1657 men we found a strong association between preparedness for decreased sexual health and experiencing bother from erectile dysfunction (OR 5.92; 95% CI 3.32-10.55). CONCLUSION: In this large-sized prospective trial, we found that preparedness before surgery for urinary problems or sexual side effects decreases bother from urinary incontinence and erectile dysfunction one year after surgery.

Degree of preservation of the neurovascular bundles during radical prostatectomy and urinary continence 1 year after surgery.

BACKGROUND: Many elderly or impotent men with prostate cancer may not receive a bundle-preserving radical prostatectomy as a result of uncertainty regarding the effect on urinary incontinence. OBJECTIVE: We searched for predictors of urinary incontinence 1 yr after surgery among surgical steps during radical prostatectomy. DESIGN, SETTING, AND PARTICIPANTS: More than 100 surgeons in 14 centers prospectively collected data on surgical steps during an open or robot-assisted laparoscopic radical prostatectomy. At 1 yr after surgery, a neutral third-party secretariat collected patient-reported information on urinary incontinence. After excluding men with preoperative urinary incontinence or postoperative irradiation, data were available for 3379 men. INTERVENTION: Surgical steps during radical prostatectomy, including dissection plane as a measure of the degree of preservation of the two neurovascular bundles. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Urinary incontinence 1 yr after surgery was measured as patient-reported use of pads. In different categories of surgical steps, we calculated the percentage of men changing pads "about once per 24 h" or more often. Relative risks were calculated as percentage ratios between categories. RESULTS AND LIMITATIONS: A strong association was found between the degree of bundle preservation and urinary incontinence 1 yr after surgery. We set the highest degree of bundle preservation (bilateral intrafascial dissection) as the reference category (relative risk = 1.0). For the men in the remaining six groups, ordered according to the degree of preservation, we obtained the following relative risks (95% confidence interval [CI]): 1.07 (0.63-1.83), 1.19 (0.77-1.85), 1.56 (0.99-2.45), 1.78 (1.13-2.81), 2.27 (1.45-3.53), and 2.37 (1.52-3.69). In the latter group, no preservation of any of the bundles was performed. The pattern was similar for preoperatively impotent men and for elderly men. Limitations of this analysis include the fact that noise influences the relative risks, due to variations between surgeons in the use of undocumented surgical steps of the procedure, variations in surgical experience and in how the surgical steps are reported, as well as variations in the metrics of patient-reported use of pads. CONCLUSIONS: We found that the degree of preservation of the two neurovascular bundles during radical prostatectomy predicts the rate of urinary incontinence 1 yr after the operation. According to our findings, preservation of both neurovascular bundles to avoid urinary incontinence is also meaningful for elderly and impotent men. PATIENT SUMMARY: We studied the degree of preservation of the two neurovascular bundles during radical prostatectomy and found that the risk of incontinence decreases if the surgeon preserves two bundles instead of one, and if the surgeon preserves some part of a bundle rather than not doing so.

Social capital and administrative contextual determinants of lack of access to a regular doctor: a multilevel analysis in southern Sweden.

BACKGROUND: The aim of this study was to investigate the influence of contextual (social capital and administrative/neo-materialist) and individual factors on lack of access to a regular doctor. METHODS: The 2000 public health survey in Scania is a cross-sectional study. A total of 13,715 persons answered a postal questionnaire, which is 59% of the random sample. A multilevel logistic regression model, with individuals at the first level and municipalities at the second, was performed. The effect (intra-class correlations, cross-level modification and odds ratios) of individual and municipality (social capital and health care district) factors on lack of access to a regular doctor was analysed using simulation method. The Deviance Information Criterion (DIC) was used as information criterion for the models. RESULTS: The second level municipality variance in lack of access to a regular doctor is substantial even in the final models with all individual and contextual variables included. The model that results in the largest reduction in DIC is the model including age, sex and individual social participation (which is a network aspect of social capital), but the models which include administrative and social capital second level factors also reduced the DIC values. CONCLUSIONS: This study suggests that both administrative health care district and social capital may partly explain the individual's self reported lack of access to a regular doctor.

Social capital, the miniaturization of community and assessment of patient satisfaction in primary healthcare: a population-based study.

AIMS: A study was undertaken to assess the impact of social participation, trust and the miniaturization of community, i.e. high social participation/low trust, on two measures of patient dissatisfaction in primary healthcare. METHODS: The Scania 2000 public-health survey is a cross-sectional, postal questionnaire study. A total of 3,456 persons aged 18-80 years who had a regular doctor within the primary healthcare system were included. A logistic regression model was used to investigate the association between the social capital variables and dissatisfaction. Multivariate analysis analysed the importance of confounders on the differences in lack of general openness and lack of information concerning treatment in accordance with social capital variables. RESULTS: Lack of openness is positively associated with low trust, the miniaturization of community and low social capital, while lack of information is not significantly associated with the miniaturization of community, but to a lesser extent with low trust and low social capital. CONCLUSIONS: Low levels of trust and the miniaturization of community may enhance non-specific patient dissatisfaction such as experience of lack of openness by the patient. In contrast, the miniaturization of community was not significantly associated with the more specific "lack of information". The results have implications for the evaluation of patient dissatisfaction.

Ethnic differences in self-reported lack of access to a regular doctor: a population-based study.

OBJECTIVE: The aim of this study was to investigate ethnic differences in self-reported lack of access to a regular doctor in Malmö, Sweden. DESIGN: The public health survey in Malmö 1994 was a cross sectional population study. Data were collected from 5600 people aged 20-80 years using a postal questionnaire. The participation rate was 71%. The population was categorised according to country of birth: born in Sweden, other Nordic countries, other Western countries, Yugoslavia, Eastern Europe, Arabic speaking countries and other countries. Multivariate logistic regression analysis was performed in order to investigate the importance of possible confounders on the differences by country of origin in lack of access to a regular doctor. RESULTS: A 56.3% proportion of all men and 48.8% of all women lacked access to a regular doctor. The odds ratios of lacking access were significantly higher among men born in Nordic countries, Arabic countries and other countries compared to men born in Sweden but disappeared after adjustment for age. The same patterns were observed for women born in Eastern Europe, Arabic countries and other countries compared to women born in Sweden, and remained after adjustment for age. In the multivariate analysis including age, education, ability to pay bills every month and self-reported health, no significant differences in lack of access to a regular doctor remained among men, while the odds ratios were significantly lower among women born in other Western countries, but still significantly higher among women born in Arabic speaking countries and all other countries. CONCLUSION: Self-reported lack of access to a regular doctor was significantly higher among men born in Nordic countries, Arabic countries and other countries compared to men born in Sweden, but all these differences disappeared after adjument for age and in the multivariate analysis. Women born in Arabic speaking countries and other countries lacked access to a regular doctor to a significantly higher extent compared with women born in Sweden, and these differences remained in the multivariate analysis.