Addressing racial disparities in prostate cancer pathology prediction models: external validation and comparison of four models of pathological outcome prediction before radical prostatectomy in the multiethnic SEARCH cohort.

BACKGROUND: Certain widely used pathological outcome prediction models that were developed in tertiary centers tend to overpredict outcomes in the community setting; thus, the Michigan Urological-Surgery Improvement Collaborative (MUSIC) model was developed in general urology practice to address this issue. Additionally, the development of these models involved a relatively small proportion of Black men, potentially compromising the accuracy of predictions in this patient group. We tested the validity of the MUSIC and three widely used nomograms to compare their overall and race-stratified predictive performance. METHODS: We extracted data from 4139 (1138 Black) men from the Shared Equal Access Regional Cancer Hospital (SEARCH) database of the Veterans Affairs health system. The predictive performance of the MUSIC model was compared to the Memorial-Sloan Kettering (MSK), Briganti-2012, and Partin-2017 models for predicting lymph-node invasion (LNI), extra-prostatic extension (EPE), and seminal vesicle invasion (SVI). RESULTS: The median PSA of Black men was higher than White men (7.8 vs. 6.8 ng/ml), although they were younger by a median of three years and presented at a lower-stage disease. MUSIC model showed comparable discriminatory capacity (AUC:77.0%) compared to MSK (79.2%), Partin-2017 (74.6%), and Briganti-2012 (76.3%), with better calibration for LNI. AUCs for EPE and SVI were 72.7% and 76.9%, respectively, all comparable to the MSK and Partin models. LNI AUCs for Black and White men were 69.6% and 79.6%, respectively, while EPE and SVI AUCs were comparable between races. EPE and LNI had worse calibration in Black men. Decision curve analysis showed MUSIC superiority over the MSK model in predicting LNI, especially among Black men. CONCLUSION: Although the discriminatory performance of all models was comparable for each outcome, the MUSIC model exhibited superior net benefit to the MSK model in predicting LNI outcomes among Black men in the SEARCH population.

Do Hispanic Puerto Rican men have worse outcomes after radical prostatectomy? Results from SEARCH.

BACKGROUND: We previously reported that outcomes after radical prostatectomy (RP) were similar among non-Hispanic Black, non-Hispanic White, and Hispanic White Veterans Affairs (VA) patients. However, prostate cancer (PC) mortality in Puerto Rican Hispanics (PRH) may be higher than in other Hispanic groups. Data focused on PRH patients is sparse; thus, we tested the association between PR ethnicity and outcomes after RP. METHODS: Analysis included men in SEARCH cohort who underwent RP (1988-2020, n = 8311). PRH patients (n = 642) were treated at the PR VA, and outcomes were compared to patients treated in the Continental US regardless of race. Logistic regression was used to test the associations between PRH and PC aggressiveness, adjusting for demographic and clinicopathological features. Multivariable Cox models were used to investigate PRH versus Continental differences in biochemical recurrence (BCR), metastases, castration-resistant PC (CRPC), and PC-specific mortality (PCSM). RESULTS: Compared to Continental patients, PRH patients had lower adjusted odds of pathological grade group ≥2 (p < 0.001), lymph node metastasis (p < 0.001), and positive margins (p < 0.001). In contrast, PRH patients had higher odds of extracapsular extension (p < 0.001). In Cox models, PRH patients had a higher risk for BCR (HR = 1.27, p < 0.001), metastases (HR = 1.49, p = 0.014), CRPC (HR = 1.80, p = 0.001), and PCSM (HR = 1.74, p = 0.011). Further adjustment for extracapsular extension and other pathological variables strengthened these findings. CONCLUSIONS: In an equal access setting, PRH RP patients generally had better pathological features, but despite this, they had significantly worse post-treatment outcomes than men from the Continental US, regardless of race. The reasons for the poorer prognosis among PRH men require further research.

Surgical Rib Fixation is Associated With Lower Mortality in Patients With Traumatic Rib Fractures.

INTRODUCTION: Nonoperative management (NOM) along with supportive care has been the adopted approach for traumatic rib fractures; however, surgical approaches have emerged recently to treat this common pathology. Despite this, there are no guidelines for surgical rib fixation in patients with traumatic rib fractures. METHODS: An institutional review board-approved retrospective cohort study was performed at the Puerto Rico Trauma Hospital aiming to compare the outcomes and complications between patients with traumatic rib fractures who undergo surgical fixation and their counterparts with NOM. The study period comprised from January 2016 through July 2020. Outcomes were evaluated with negative binomial and logistic regressions. RESULTS: Fifty patients were identified for the surgical rib fixation group, who were matched to 150 patients who received NOM. The majority of patients were male (91.5%), with a median (interquartile range) age of 53 (29) years. Concomitant chest injuries were significantly more prevalent in the operative group, such as flail segment (P < 0.001), number of fractures (P < 0.001), and displaced rib fractures (P < 0.001). Although hospital length of stay was 25% (95% confidence interval: 1.02-1.54) longer in the surgical group, this intervention was associated with an 85% (95% confidence interval: 0.03-0.70) lower mortality rate when compared to conservative management. CONCLUSIONS: Rib fixation may offer some benefits in selected patients with traumatic rib fractures, such as those with bilateral rib fractures, multiple displaced rib fractures, flail segment, and concomitant thoracic injuries. This study may serve as a guide for treatment strategy and patient selection regarding the surgical management of traumatic rib fractures.

Understanding Current Demographics, Practice Patterns, and Concerns of Women in Urology: Analysis From the 2022 Society of Women in Urology Census Task Force.

OBJECTIVE: To describe the current demographics, needs, and challenges of women in Urology throughout the United States, including active Urologists as well as urologic trainees. METHODS: An electronic survey was distributed via email and social media sites to all members of the Society of Women in Urology, including residents, fellows, and female urologists practicing in the US and its territories, between February 2022 and May 2022. The survey collected information on demographics, practice type, workplace, personal, family issues, barriers, and career plans from all respondents. RESULTS: Of the estimated 1375 women urologists and trainees based on AUA census data, 379 responses (27.6% response rate) were received. Almost all respondents (98%) are members of the AUA. The average age was 42.9years (SD 18.6). In terms of ethnicity, most self-reported as White 71.0%, followed by 16.4% Asian or Asian American, and 6.3% African American. The majority reported practicing in urban locations (63.5%) at an academic setting (55.7%), followed by similar distribution between private practice and hospital-employed settings (17.0% and 16.7%, respectively). The vast majority, 89.6%, reported working full-time, while only 10.4% worked part-time. The average hours of work per week were 56.7 (SD 14.5). In terms of personal demographics, 81.9% were married, 17.3% were single and 1% did not answer. 68.8% of responders had children, with the majority of these children being born during or after training. CONCLUSION: Based on the findings, although female urologists have increased in numbers, certain ethnicities are under-represented. Additional surveys and engagement of current trainees and practitioners are needed to identify further areas of intervention for specific needs.

Are associations between obesity and prostate cancer outcomes following radical prostatectomy the same in smokers and non-smokers? Results from the SEARCH Cohort.

PURPOSE: Obesity and smoking have been associated with poor prostate cancer (PC) outcomes. We investigated associations between obesity and biochemical recurrence (BCR), metastasis, castrate resistant-PC (CRPC), PC-specific mortality (PCSM), and all-cause mortality (ACM) and examined if smoking modified these associations. METHODS: We analyzed SEARCH Cohort data from men undergoing RP between 1990 and 2020. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between body mass index (BMI) as a continuous variable and weight status classifications (normal: 18.5 ≤ 25 kg/m2; overweight: 25-29.9 kg/m2; obese: ≥ 30 kg/m2) and PC outcomes. RESULTS: Among 6,241 men, 1,326 (21%) were normal weight, 2,756 (44%) overweight and 2159 (35%) obese; 1,841 (30%) were never-smokers, 2,768 (44%) former and 1,632 (26%) current-smokers. Among all men, obesity was associated with non-significant increased risk of PCSM, adj-HR = 1.71; 0.98-2.98, P = 0.057, while overweight and obesity were inversely associated with ACM, adj-HR = 0.75; 0.66-0.84, P < 0.001 and adj-HR = 0.86; 0.75-0.99, P = 0.033, respectively. Other associations were null. BCR and ACM were stratified for smoking status given evidence for interactions (P = 0.048 and P = 0.054, respectively). Among current-smokers, overweight was associated with an increase in BCR (adj-HR = 1.30; 1.07-1.60, P = 0.011) and a decrease in ACM (adj-HR = 0.70; 0.58-0.84, P < 0.001). Among never-smokers, BMI (continuous) was associated with an increase in ACM (adj-HR = 1.03; 1.00-1.06, P = 0.033). CONCLUSIONS: While our results are consistent with obesity as a risk factor for PCSM, we present evidence of effect modification by smoking for BCR and ACM highlighting the importance of stratifying by smoking status to better understand associations with body weight.

Diabetes and Prostate Cancer Outcomes in Men with Nonmetastatic Castration-Resistant Prostate Cancer: Results from the SEARCH Cohort.

BACKGROUND: The prognosis of diabetic men with advanced prostate cancer is poorly understood and understudied. Hence, we studied associations between diabetes and progression to metastases, prostate cancer-specific mortality (PCSM) and all-cause mortality (ACM) in men with nonmetastatic castration-resistant prostate cancer (nmCRPC). METHODS: Data from men diagnosed with nmCRPC between 2000 and 2017 at 8 Veterans Affairs Health Care Centers were analyzed using Cox regression to determine HRs and 95% confidence intervals (CI) for associations between diabetes and outcomes. Men with diabetes were classified according to: (i) ICD-9/10 codes only, (ii) two HbA1c values > 6.4% (missing ICD-9/10 codes), and (iii) all diabetic men [(i) and (ii) combined]. RESULTS: Of 976 men (median age: 76 years), 304 (31%) had diabetes at nmCRPC diagnosis, of whom 51% had ICD-9/10 codes. During a median follow-up of 6.5 years, 613 men were diagnosed with metastases, and 482 PCSM and 741 ACM events occurred. In multivariable-adjusted models, ICD-9/10 code-identified diabetes was inversely associated with PCSM (HR, 0.67; 95% CI, 0.48-0.92) while diabetes identified by high HbA1c values (no ICD-9/10 codes) was associated with an increase in ACM (HR, 1.41; 95% CI, 1.16-1.72). Duration of diabetes, prior to CRPC diagnosis was inversely associated with PCSM among men identified by ICD-9/10 codes and/or HbA1c values (HR, 0.93; 95% CI, 0.88-0.98). CONCLUSIONS: In men with late-stage prostate cancer, ICD-9/10 'code-identified' diabetes is associated with better overall survival than 'undiagnosed' diabetes identified by high HbA1c values only. IMPACT: Our data suggest that better diabetes detection and management may improve survival in late-stage prostate cancer.

Metabolic syndrome is associated with aggressive prostate cancer regardless of race.

PURPOSE: Recent meta-analyses suggest the Metabolic Syndrome (MS) increases high-grade prostate cancer (PC), although studies are inconsistent and few black men were included. We investigated MS and PC diagnosis in black and white men undergoing prostate biopsy in an equal access healthcare system. We hypothesized MS would be linked with aggressive PC, regardless of race. METHODS: Among men undergoing prostate biopsy at the Durham Veterans Affairs Hospital, medical record data abstraction of diagnosis or treatment for hypertension (≥ 130/85 mmHg), dyslipidemia (HDL < 40 mg/dL), hypertriglyceridemia (≥ 150 mg/dL), diabetes, hyperglycemia (fasting glucose ≥ 100 ml/dL), and central obesity (waist circumference ≥ 40 inches) were done. Biopsy grade group (GG) was categorized as low (GG1) or high (GG2-5). Multinomial logistic regression was used to examine MS (3-5 components) vs. no MS (0-2 components) and diagnosis of high grade and low grade vs. no PC, adjusting for potential confounders. Interactions between race and MS were also tested. RESULTS: Of 1,051 men (57% black), 532 (51%) had MS. Men with MS were older, more likely to be non-black, and had a larger prostate volume (all p ≤ 0.011). On multivariable analysis, MS was associated with high-grade PC (OR = 1.73, 95% CI 1.21-2.48, p = 0.003), but not overall PC (OR = 1.17, 95% CI 0.88-1.57, p = 0.29) or low grade (OR = 0.87, 95% CI 0.62-1.21, p = 0.39). Results were similar in black and non-black men (all p-interactions > 0.25). CONCLUSION: Our data suggest that metabolic dysregulation advances an aggressive PC diagnosis in both black and non-black men. If confirmed, prevention of MS could reduce the risk of developing aggressive PC, including black men at higher risk of PC mortality.

Accommodating heterogeneous missing data patterns for prostate cancer risk prediction.

BACKGROUND: We compared six commonly used logistic regression methods for accommodating missing risk factor data from multiple heterogeneous cohorts, in which some cohorts do not collect some risk factors at all, and developed an online risk prediction tool that accommodates missing risk factors from the end-user. METHODS: Ten North American and European cohorts from the Prostate Biopsy Collaborative Group (PBCG) were used for fitting a risk prediction tool for clinically significant prostate cancer, defined as Gleason grade group ≥ 2 on standard TRUS prostate biopsy. One large European PBCG cohort was withheld for external validation, where calibration-in-the-large (CIL), calibration curves, and area-underneath-the-receiver-operating characteristic curve (AUC) were evaluated. Ten-fold leave-one-cohort-internal validation further validated the optimal missing data approach. RESULTS: Among 12,703 biopsies from 10 training cohorts, 3,597 (28%) had clinically significant prostate cancer, compared to 1,757 of 5,540 (32%) in the external validation cohort. In external validation, the available cases method that pooled individual patient data containing all risk factors input by an end-user had best CIL, under-predicting risks as percentages by 2.9% on average, and obtained an AUC of 75.7%. Imputation had the worst CIL (-13.3%). The available cases method was further validated as optimal in internal cross-validation and thus used for development of an online risk tool. For end-users of the risk tool, two risk factors were mandatory: serum prostate-specific antigen (PSA) and age, and ten were optional: digital rectal exam, prostate volume, prior negative biopsy, 5-alpha-reductase-inhibitor use, prior PSA screen, African ancestry, Hispanic ethnicity, first-degree prostate-, breast-, and second-degree prostate-cancer family history. CONCLUSION: Developers of clinical risk prediction tools should optimize use of available data and sources even in the presence of high amounts of missing data and offer options for users with missing risk factors.

Elderly Admission Trends at the Puerto Rico Trauma Hospital: A Time-Series Analysis.

INTRODUCTION: The aging process places the elderly, a worldwide increasing age group, at an increased risk for trauma. This study aims to explore changes over time in admission rates, sociodemographical, clinical, and injury-related data in elderly patients (aged ≥65 y) admitted to the Puerto Rico Trauma Hospital (PRTH) during 2000-2019. MATERIALS AND METHODS: A time-series analysis was conducted. Admission rates were analyzed by fitting an exponential growth curve model. Trends were assessed using the Cochrane-Armitage and Cuzick tests for categorical and continuous data, respectively. RESULTS: Elderly admission rates to the PRTH have shown growth over the past 2 decades, from 6.2 cases per 100 overall admissions in 2000 to 18.2 in 2019. This trend is projected to continue with estimated 24.8 (95% CI: 21.7-27.8) cases per 100 overall admissions in 2023. Trends for mechanisms of injury such as motor vehicle accidents and pedestrians showed a significant decrease, whereas falls presented a clear positive trend, showing an increase from 25.6% in 2000-2004 to 46.2% in 2015-2019. Both Injury Severity Score ≥25 and Glasgow Coma Scale ≤8 declined significantly through time. Finally, in-hospital mortality presented a decreasing trend from 31.7% in 2000-2004 to 21.5% in 2015-2019. CONCLUSIONS: Our analysis demonstrates an increase over time in elderly admissions, especially fall-related trauma. Also, it projects this upward trend will continue. This imposes new challenges for PRTH and other healthcare services and is a gateway for the implementation of adapted clinical management.

Defining the Impact of Family History on Detection of High-grade Prostate Cancer in a Large Multi-institutional Cohort.

BACKGROUND: The risk of high-grade prostate cancer, given a family history of cancer, has been described in the general population, but not among men selected for prostate biopsy in an international cohort. OBJECTIVE: To estimate the risk of high-grade prostate cancer on biopsy based on a family history of cancer. DESIGN, SETTING, AND PARTICIPANTS: This is a multicenter study of men undergoing prostate biopsy from 2006 to 2019, including 12 sites in North America and Europe. All sites recorded first-degree prostate cancer family histories; four included more detailed data on the number of affected relatives, second-degree relatives with prostate cancer, and breast cancer family history. OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS: Multivariable logistic regressions evaluated odds of high-grade (Gleason grade group ≥2) prostate cancer. Separate models were fit for family history definitions, including first- and second-degree prostate cancer and breast cancer family histories. RESULTS AND LIMITATIONS: A first-degree prostate cancer family history was available for 15 799 men, with a more detailed family history for 4617 (median age 65 yr, both cohorts). Adjusted odds of high-grade prostate cancer were 1.77 times greater (95% confidence interval [CI] 1.57-2.00, p < 0.001, risk ratio [RR] = 1.40) with first-degree prostate cancer, 1.38 (95% CI 1.07-1.77, p = 0.011, RR = 1.22) for second-degree prostate cancer, and 1.30 (95% CI 1.01-1.67, p = 0.040, RR = 1.18) for first-degree breast cancer family histories. Interaction terms revealed that the effect of a family history did not differ based on prostate-specific antigen but differed based on age. This study is limited by missing data on race and prior negative biopsy. CONCLUSIONS: Men with indications for biopsy and a family history of prostate or breast cancer can be counseled that they have a moderately increased risk of high-grade prostate cancer, independent of other risk factors. PATIENT SUMMARY: In a large international series of men selected for prostate biopsy, finding a high-grade prostate cancer was more likely in men with a family history of prostate or breast cancer.

The effect of the lockdown executive order during the COVID-19 pandemic in recent trauma admissions in Puerto Rico.

BACKGROUND: The COVID-19 pandemic led to world-wide restrictions on social activities to curb the spread of this disease. Very little is known about the impact of these restrictions on trauma centers. Our objective was to determine the effect of the pandemic-associated lockdown on trauma admissions, patient's demographics, mechanisms of injury, injury severity, and outcomes in the Puerto Rico Trauma Hospital. METHODS: An IRB-approved quasi-experimental study was performed to assess the impact of the restrictions by comparing trauma admissions during the lockdown (March 15, 2020 - June 15, 2020) with a control period (same period in 2017-2019). Comparisons were done using the Pearson's chi-square test, Fisher exact test, or Mann-Whitney U test, as appropriate. A negative binomial model was fitted to estimate the incidence rate ratio for overall admissions among pre-lockdown and during-lockdown periods. Statistical significance was set at p < 0.05. RESULTS: A total of 308 subjects were admitted during the quarter of study for 2017; 323, for 2018; 347, for 2019; and 150, for 2020. The median (interquartile range) age of patients rose significantly from 40 (33) years to 49 (30) years (p < 0.001) for the lockdown period compared to the historical period. Almost all mechanisms of injury (i.e., motor vehicle accident, assault, pedestrian, burn, suicide attempt, other) had a slight non-significant reduction in the percentage of patients presenting with an injury. Instead, falls experienced an increase during the lockdown period (18.9% vs. 26.7%; p = 0.026). Moreover, the proportion of severe cases decreased, as measured by an injury severity score (ISS) > 15 (37.3% vs. 26.8%; p = 0.014); while there were no differences in the median hospital length of stay and the mortality rate between the comparison groups. Finally, the decrease in overall admissions registered during the lockdown accounts for a 59% (IRR 0.41; 95% CI 0.31-0.54) change compared to the pre-lockdown period, when controlling for sex, age, mechanism of injury, and ISS. CONCLUSIONS: Following periods of social isolation and curfews, trauma centers can expect drastic reductions in their overall patient volume with associated changes in trauma patterns. Our findings will help inform new interventions and improve healthcare preparedness for future or similar circumstances.

Do Hispanic Men Have Worse Outcomes After Radical Prostatectomy? Results From SEARCH.

OBJECTIVE: To examine the associations between ethnicity and outcomes after radical prostatectomy (RP) among Hispanics. While non-Hispanic Black men have worse prostate cancer (PC) outcomes, there are limited data on outcomes of Hispanic men, especially after RP. METHODS: We identified 3789 White men who underwent RP between 1988 and 2017 in the Shared Equal Access Regional Cancer Hospital database. Men were categorized as Hispanic or non-Hispanic. Logistic regression was used to test the association between ethnicity and PC adverse features. Cox models were used to test the association between ethnicity and biochemical recurrence (BCR), metastases, and castration-resistant PC (CRPC). All models were adjusted for age, prostate-specific antigen, clinical stage, biopsy grade group, surgery year, and surgical center. RESULTS: Of 3789 White men, 236 (6%) were Hispanic. Hispanic men had higher prostate-specific antigen, but all other characteristics were similar between ethnicities. On multivariable analysis, there was no difference between ethnicities in odds of extracapsular extension, seminal vesicle invasion, positive margins, positive lymph nodes, or high-grade disease (odds ratio 0.62-0.89, all P > .07). A total of 1168 men had BCR, 182 developed metastasis, and 132 developed CRPC. There was no significant association between Hispanic ethnicity and risk of BCR, metastases, or CRPC (hazards ratio 0.39-0.85, all P > .06). CONCLUSION: In an equal access setting, we found no evidence Hispanic White men undergoing RP had worse outcomes than non-Hispanic White men. In fact, all hazard ratios were <1 and although they did not achieve statistical significance, suggest perhaps slightly better outcomes for Hispanic men. Larger studies are needed to confirm findings.

Morbidity and mortality of Hispanic trauma patients with diabetes mellitus.

PURPOSE: DM and trauma are leading causes of death in Hispanic patients, yet the interaction between them remains obscure. We aimed to assess the complications and in-hospital mortality rate of Hispanic diabetic trauma patients. METHODS: A retrospective cohort study was carried out using data from the Puerto Rico Trauma Hospital databank. Patients were matched based on gender, age, mechanism of injury, Glasgow Coma Scale, and Injury Severity Score using propensity-score matching. From 2000 to 2014, a total of 1134 patients with DM were compared to 1134 patients who did not have DM. The outcomes measured were hospital and TICU lengths of stay, days on mechanical ventilation, complications, and in-hospital mortality rate. A logistic regression model was carried out to evaluate the relationship of DM with complications and mortality after trauma. RESULTS: Hispanic patients with DM had longer hospital and TICU stays and required mechanical ventilation for extended periods. Complications, predominantly of an infectious nature, were more common among DM patients than they were among non-DM patients: 31.3% in the DM group vs. 11.6% in the non-DM group (OR 3.46; 95% CI 2.77-4.31). Despite an increase in the number of complications, DM was not associated with higher in-hospital mortality rates. CONCLUSIONS: DM is associated with a twofold increase in complications in Hispanic diabetic trauma patients, which may account for their longer hospital and TICU stays. This indicates that diabetic Hispanic trauma patients may need earlier and more aggressive intervention to reduce their risk of developing complications.

Is Body Mass Index the Best Adiposity Measure for Prostate Cancer Risk? Results From a Veterans Affairs Biopsy Cohort.

OBJECTIVE: To test multiple adiposity measures and prostate cancer (PC) risk in men undergoing prostate biopsy. We hypothesized that body mass index (BMI), body fat, and waist circumference would be highly correlated, and all would be associated with aggressive PC, but not overall risk. SUBJECTS AND METHODS: A case (483)-control (496) study among men undergoing prostate biopsy from 2007 to 2016 was conducted at the Durham Veterans Affairs Medical Center. Anthropometric and self-reported measurements were taken. Percent body fat was measured. Associations between adiposity measures and PC risk and high-grade PC (Gleason ≥7) were examined using logistic regression. RESULTS: BMI, percent body fat, and waist circumference were highly correlated (ρ ≥ .79) (P < .001). On multivariable analysis, BMI (P = .011) was associated with overall PC risk, but percent body fat (P = .16) and waist circumference (P = .19) were not. However, all adiposity measurements were associated with high-grade disease (P < .001). We found a strong relationship between self-reported and measured weight (ρ = .97) and height (ρ = .92). CONCLUSION: BMI, body fat, and waist circumference were all highly correlated and associated with aggressive PC. This study supports the idea that higher adiposity is selectively associated with high-grade PC and reinforces the continued use of self-reported BMI as a measure of obesity in epidemiologic studies of PC.