Primary Palliative Care in Urology: Quality Improvement Summit 2021-2022.

INTRODUCTION: The AUA convened a 2021-2022 Quality Improvement Summit to bring together interdisciplinary providers to inform the current state and to discuss potential strategies for integrating primary palliative care into urology practice. We hypothesized that the Summit findings would inform a scalable primary palliative care model for urology. METHODS: The 3-part summit reached a total of 160 interdisciplinary health care professionals. Webinar 1, "Building a Primary Palliative Care Model for Urology," focused on a urologist's role in palliative care. Webinar 2, "Perspectives on Increasing the Use of Palliative Care in Advanced Urologic Disease," addressed barriers to possible implementation of a primary palliative care model. The in-person Summit, "Laying the Foundation for Primary Palliative Care in Urology," focused on operationalization of primary palliative care, clinical innovations needed, and relevant metrics. RESULTS: Participants agreed that palliative care is needed early in the disease course for patients with advanced disease, including those with benign and malignant conditions. The group agreed about the important domains that should be addressed as well as the interdisciplinary providers who are best suited to address each domain. There was consensus that a primary "quarterback" was needed, encapsulated in a conceptual model-UroPal-with a urologist at the hub of care. CONCLUSIONS: The Summit provides the field of urology with a framework and specific steps that can be taken to move urology-palliative care integration forward. Urologists are uniquely positioned to provide primary palliative care for their many patients with serious illness, both in the surgical and chronic care contexts.

Linguistic Differences Based on Gender and Race in Urology Application Personal Statements: A Comparison of 2017 and 2023 Applications.

While diversity and inclusion efforts have increased in urology, comparative analysis of personal statements from 2016-2017 and 2022-2023 residency applications showed few linguistic changes over time by gender or race/ethnicity. These results suggest the need for directed efforts to engage, mentor, and coach females and underrepresented minorities during medical school and the urology application process.

Palliative care knowledge, attitudes, and experiences amongst patients with bladder cancer and their caregivers.

OBJECTIVES: Palliative care is underutilized amongst patients with bladder cancer despite guideline recommendations and known benefits. In order to uncover potential access barriers, we sought to describe patient and caregiver knowledge, attitudes and experiences surrounding palliative care. METHODS: We surveyed 272 patients with bladder cancer and their caregivers through the Bladder Cancer Advocacy Network Patient Survey Network. In addition to collecting demographic, socioeconomic, and clinical characteristics, previously studied and validated questionnaires on palliative care knowledge and beliefs were administered. Patients and caregivers were also queried regarding their experiences with palliative care consultation. RESULTS: Survey respondents demonstrated highly accurate knowledge of palliative care services. Attitudes and beliefs surrounding palliative care were overall positive. Caregivers demonstrated better knowledge and more positive beliefs of palliative care compared to patients. Despite an overall positive sentiment toward palliative care, only 9% of the cohort had palliative care consultation as part of their cancer treatment plan. Most patients with muscle-invasive or metastatic bladder cancer wished that palliative care had been discussed by their providers. CONCLUSIONS: A subset of bladder cancer patients possess accurate knowledge and positive beliefs of palliative care. Palliative care is infrequently discussed during the treatment of bladder cancer, with patients and their caregivers expressing desire for palliative care to be discussed more often. Provider education surrounding palliative care services is imperative to improving access for bladder cancer patients and caregivers.

Is There a Role for Palliative Services and Supportive Care in Managing Advanced Penile Cancer?

OBJECTIVES: We aim to review the benefits of palliative care, describe why a palliative approach to care is needed for patients with advanced penile squamous cell carcinoma and propose ways in which oncology nurses can improve access to and provision of palliative care. DATA SOURCES: A review of the literature was performed and identified a range of randomized trials and systematic reviews regarding the benefits of palliative care in this patient group. Cohort studies of patients with penile cancer were used to describe the psychosocial and physical disease burden of penile cancer. CONCLUSION: Throughout each phase of penile cancer and its treatment, oncology nurses can engage in care that goes beyond cancer-directed treatments to address the whole person, thereby improving quality of life by delivering person-centered palliative care in line with individual needs. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses are in key positions to explore many concerns that patients with penile cancer have for themselves or their caregivers. Through speaking directly with patients and caregivers, oncology nurses can uncover sources of distress, assess for unmet needs, and advocate for improved primary palliative care or early referral to specialty palliative care teams.

Linguistic Differences in Personal Statements of Urology Residency Applicants by Self-Reported Race and Ethnicity.

OBJECTIVES: To assess a potential source of bias that could contribute to underrepresentation of minorities in urology, we analyzed differences in linguistic characteristics in personal statements between urology residency applicants of various racial and ethnic groups. METHODS: Personal statements submitted by urology residency applicants to a urology program were evaluated with Linguistic Inquiry and Word Count, a validated text analysis program. Analyzed statements and application characteristics were compared according to self-identified race/ethnicity of the applicant using multivariable analysis and independent sample T-tests. RESULTS: Of 342 submitted personal statements, 181 applicants self-identified as White non-Hispanic, 86 as Asian, and 75 as "underrepresented in medicine" (URM) including Black and Hispanic/Latino applicants. Asian and URM applicants listed more research projects (11.7 and 12.9 vs 8.8, P = .01) and URM applicants had slightly lower USMLE Step 1 scores (238.5 vs 244.6, P = .01) compared to White applicants. When evaluating personal statements, all applicants wrote with the same degree of analytical thinking. Asian applicants scored lower in authenticity (P = .03) and emotional tone (P = .04) while URM applicants scored higher in clout (P = .04) compared to White applicants. In use of pronouns, Asian applicants used 'we/us/our' more often (P < .01), URM applicants used 'you' more often (P = .02), and White applicants used 'I' more often (P = .01). CONCLUSION: Significant linguistic differences exist among urology personal statements by racial/ethnic groups that may perpetuate stereotypes and bias in the application process. Appreciating these differences may help applicants avoid possibly detrimental linguistics and help residency programs recruit and support urology applicants from underrepresented backgrounds.

High-intensity end-of-life care among Medicare beneficiaries with bladder cancer.

OBJECTIVES: To quantify the proportion of patients receiving high-intensity end-of-life care, identify associated risk factors, and assess how receipt of palliative care impact end-of-life care; as the delivery of such care, and how it relates to palliative care, has not been reported in bladder cancer SUBJECTS AND METHODS: We conducted a retrospective cohort study of patients with bladder cancer who died within 1 year of diagnosis using Surveillance, Epidemiology, and End Results linked Medicare data. The primary outcome was a composite measure of high-intensity end-of-life care (>1 hospital admission, >1 ED visit, or ≥1 ICU admission within the last month of life; receipt of chemotherapy within the last 2 weeks of life; or acute care in-hospital death). Secondary outcomes included the use of such care over time and any association with the use of palliative care. A generalized linear mixed model assessed for independent determinants. RESULTS: Overall, 45% of patients received high-intensity end-of-life care. This proportion decreased over time. Patients receiving high-intensity care had higher rates of comorbidities, advanced bladder cancer, and nonbladder cancer cause of death. These patients more often received palliative care but, compared to those not receiving high-intensity care, this occurred farther removed from bladder cancer diagnosis and closer to death. CONCLUSIONS: Nearly half of Medicare beneficiaries with bladder cancer who die within 1 year of diagnosis receive high-intensity care at the end of life. Palliative care was seldom used and only very near the time of death.

Gender Bias in Surgical Oncology Fellowship Recommendation Letters: Gaining Progress.

OBJECTIVE: Gender bias has been identified in letters of recommendation (LOR) in many different surgical training fields. Among surgeons, women comprise over 30% of the full-time faculty positions nationally and surgical oncology is one of the most gender diverse surgical subspecialties. We sought to determine if bias existed in LOR submitted to a Complex General Surgical Oncology (CGSO) fellowship. DESIGN: LOR for the CGSO fellowship were retrospectively analyzed from applicants at a single institution over an 8-year period (2013-2020). The linguistic content of the letters was analyzed using Linguistic Inquiry and Word Count (LIWC2015), a validated text analysis program. Using multivariable analysis, LOR were compared by gender of both applicant and letter writer to explore the association between gender and the characteristics of the applicants and letter writers. SETTING: University of North Carolina at Chapel Hill (UNC), Division of Surgical Oncology and Endocrine Surgery. PARTICIPANTS: Applicants interviewed for the CSGO fellowship program at the UNC from 2013 to 2020 as well as all applicants from the 2018 application cycle, regardless of interview status. RESULTS: About 841 letters from 219 interviewed applicants throughout the 2013 to 2020 surgical oncology fellowship application cycles were included. No difference in authenticity, clout, analytic thinking, or emotional tone of the letters was seen when comparing men and women applicants. Of the 41 word categories analyzed, only "references to achievement" in LOR written for women was significantly higher when compared to LOR written for men (p = 0.01). Interestingly, significantly more women applicants had at least 1 LOR written by a woman (p = 0.04). A subset analysis of all applicants regardless of interview status from the 2018 cycle included 294 LOR from 77 applicants. With the inclusion of noninterviewed applicants, LOR for men had more analytic tone than LOR for women (p = 0.02), otherwise there were no significant differences between the groups. CONCLUSIONS: Very few differences in LOR were found for applicants at a CGSO fellowship program based on applicant or letter writer gender. The lack of gender bias demonstrates progress within the field of surgical oncology, likely a result of recent work and educational effort in this area. Efforts to expand this progress into other surgical sub-specialties are necessary.

Gender-Based Differences in Urology Residency Applicant Personal Statements.

OBJECTIVE: To gain insight into the perceptions of urology held by medical students as they enter the field, we analyzed the linguistic characteristics and gender differences in personal statements written by urology residency program applicants. METHODS: Personal statements were abstracted from residency applications to a urology residency program. Linguistic Inquiry and Word Count, a validated text analysis software, characterized the linguistic content of the statements. Analyzed statements were compared according to gender of the applicant using multivariate analysis, examining the association of applicant gender and statement characteristics. Multivariate analysis was also performed to determine the association of personal statement characteristics with matching into urology residency. RESULTS: Of 342 analyzed personal statements, no significant difference was found in statement characteristics between matched and unmatched applicants. Male and female applicants wrote with the same degree of overall analytical thinking, authenticity, and emotional tone. Clout, a measure of portrayed confidence, was low for both genders. Female applicants used more social and affective process words. Male applicants used more words indicating a sense of community and acceptance. Female applicants had more references to women within their statements. CONCLUSION: Significant linguistic differences exist among personal statements written by men and women applying to urology residency. Word usage differences follow societal gender norms. Statement content demonstrates a difference between genders in perceived sense of belonging, highlighting the importance of gender concordant mentorship within the field.

Outpatient Panniculectomy and Skin Graft for Adult Buried Penis.

OBJECTIVE: To demonstrate a technique for performing panniculectomy and skin graft for a patient with adult buried penis, highlighting a number of technical modifications that allow for the procedure to be performed as an outpatient. METHODS: Pannus is mobilized with a modified trapezoid incision, leaving superior attachments intact for skin graft harvest. Diseased penile skin is removed, defect is measured, and an appropriately sized split thickness skin graft is harvested from the pannus in 2-inch sections at a depth of 18/1000. The unmeshed graft is applied to the penis and covered with a bolster that is secured to the penis for 5-7 days. Patients are discharged postoperative day 0 or 1. RESULTS: From 2017 to 2019, 19 patients underwent outpatient adult-buried penis repair. Median follow-up was 11.5 months. Median age was 70 years, median body mass index was 43.4, 9 (47%) patients had pathologically confirmed lichen sclerosus. Graft take was ≥95% in all patients. Complications included cellulitis (5, 26%) and minor dehiscence (3, 16%). No patients experienced deep vein thrombosis. CONCLUSION: Outpatient panniculectomy and skin graft is an effective treatment option for patients with adult buried penis.

The Presence of Gender Bias in Letters of Recommendations Written for Urology Residency Applicants.

OBJECTIVE: To determine whether implicit gender bias exists in the urology residency application process, we compared linguistic differences in letters of recommendation (LOR) submitted for male and female applicants. METHODS: LOR were abstracted from residency applications to a urology residency program. Linguistic Inquiry and Word Count, a validated text analysis software program, characterized the linguistic content of the letters. Analyzed letters were compared according to gender of the applicant using multivariable analysis, examining the association of applicant gender, letter writer, and letter characteristics. Multivariable analysis was also performed to determine the association of letter characteristics with matching into a urology residency. RESULTS: Of 460 letters evaluated, letters for male applicants are written in a more authentic tone compared to letters written for female applicants. Letters written for male applicants contain significantly more references to personal drive, work, and power than letters written for female applicants. Significant differences are maintained on multivariable analysis when controlling for race and Step 1 score of the applicant. Letters with references to power were significantly more likely to be associated with an applicant who matched into urology than an applicant who didn't match. CONCLUSION: Significant linguistic differences exist among LOR written for men and women applying into urology, suggesting that gender bias may permeate resident recruitment. These differences may affect the likelihood of women matching into urology.

Financial Toxicity among Patients with Bladder Cancer: Reasons for Delay in Care and Effect on Quality of Life.

PURPOSE: Costly surveillance and treatment of bladder cancer can lead to financial toxicity, a treatment related financial burden. Our objective was to define the prevalence of financial toxicity among patients with bladder cancer and identify delays in care and its effect on health related quality of life. MATERIALS AND METHODS: We identified patients with bladder cancer in the University of North Carolina Health Registry/Cancer Survivorship Cohort. Financial toxicity was defined as agreement with having "to pay more for medical care than you can afford." Health related quality of life was measured using general and cancer specific validated questionnaires. Statistical analyses were performed using the Fisher exact test and the Student t-test. RESULTS: A total of 138 patients with bladder cancer were evaluated. Median age was 66.9 years, 75% of the patients were male and 89% were white. Of the participants 33 (24%) endorsed financial toxicity. Participants who were younger (p = 0.02), black (p = 0.01), reported less than a college degree (p = 0.01) and had noninvasive disease (p = 0.04) were more likely to report financial toxicity. On multivariable analysis only age was a significant predictor of financial toxicity. Patients who endorsed financial toxicity were more likely to report delaying care (39% vs 23%, p = 0.07) due to the inability to take time off work or afford general expenses. On general health related quality of life questionnaires patients with financial toxicity reported worse physical and mental health (p = 0.03 and <0.01, respectively), and lower cancer specific health related quality of life (p = 0.01), physical well-being (p = 0.01) and functional well-being (p = 0.05). CONCLUSIONS: Financial toxicity is a major concern among patients with bladder cancer. Younger patients were more likely to experience financial toxicity. Those who endorsed financial toxicity experienced delays in care and poorer health related quality of life, suggesting that treatment costs should have an important role in medical decision making.