Breast cancer risk factors by mode of detection among screened women in the Cancer Prevention Study-II.

BACKGROUND: Identifying risk factors for women at high risk of symptom-detected breast cancers that were missed by screening would enable targeting of enhanced screening regimens. To this end, we examined associations of breast cancer risk factors by mode of detection in screened women from the Cancer Prevention Study (CPS)-II Nutrition Cohort. METHODS: Among 77,206 women followed for a median of 14.8 years, 2711 screen-detected and 1281 symptom-detected breast cancer cases were diagnosed. Multivariable-adjusted associations were estimated using joint Cox proportional hazards regression models with person-time calculated contingent on screening. RESULTS: Factors associated with higher risks of symptom-detected and screen-detected breast cancer included current combined hormone therapy (HT) use (HR 2.07, 95% CI 1.72-2.48 and 1.45, 1.27-1.65, respectively) and history of benign breast disease (1.85, 1.64-2.08 and 1.43, 1.31-1.55, respectively). Current estrogen-only HT use was associated with symptom-detected (1.40, 1.15-1.71) but not screen-detected (0.95, 0.83-1.09) breast cancer. Higher risk of screen-detected but not symptom-detected breast cancer was observed for obese vs. normal body mass index (1.22, 1.01-1.48 and 0.76, 0.56-1.01, respectively), per 3 h/day sitting time (1.10, 1.04-1.16 and 0.97, 0.89-1.06, respectively), and ≥ 2 drinks per day vs. nondrinker (1.40, 1.16-1.69 and 1.27, 0.97-1.66, respectively). CONCLUSIONS: Differences in risk factors for symptom-detected vs. screen-detected breast cancer were observed and most notably, use of combined and estrogen-only HT and a history of benign breast disease were associated with increased risk of symptomatic detected breast cancer. IMPACT: If confirmed, these data suggest that such women may benefit from more intensive screening to facilitate early detection.

American Cancer Society guideline for diet and physical activity for cancer prevention.

The American Cancer Society (ACS) publishes the Diet and Physical Activity Guideline to serve as a foundation for its communication, policy, and community strategies and, ultimately, to affect dietary and physical activity patterns among Americans. This guideline is developed by a national panel of experts in cancer research, prevention, epidemiology, public health, and policy, and reflects the most current scientific evidence related to dietary and activity patterns and cancer risk. The ACS guideline focuses on recommendations for individual choices regarding diet and physical activity patterns, but those choices occur within a community context that either facilitates or creates barriers to healthy behaviors. Therefore, this committee presents recommendations for community action to accompany the 4 recommendations for individual choices to reduce cancer risk. These recommendations for community action recognize that a supportive social and physical environment is indispensable if individuals at all levels of society are to have genuine opportunities to choose healthy behaviors. This 2020 ACS guideline is consistent with guidelines from the American Heart Association and the American Diabetes Association for the prevention of coronary heart disease and diabetes as well as for general health promotion, as defined by the 2015 to 2020 Dietary Guidelines for Americans and the 2018 Physical Activity Guidelines for Americans.

Prevalence of Cigarette Smoking among Patients with Different Histologic Types of Kidney Cancer.

BACKGROUND: Cigarette smoking is causally linked to renal cell carcinoma (RCC). However, associations for individual RCC histologies are not well described. Newly available data on tobacco use from population-based cancer registries allow characterization of associations with individual RCC types. METHODS: We analyzed data for 30,282 RCC cases from 8 states that collected tobacco use information for a National Program of Cancer Registry project. We compared the prevalence and adjusted prevalence ratios (aPR) of cigarette smoking (current vs. never, former vs. never) among individuals diagnosed between 2011 and 2016 with clear cell RCC, papillary RCC, chromophobe RCC, renal collecting duct/medullary carcinoma, cyst-associated RCC, and unclassified RCC. RESULTS: Of 30,282 patients with RCC, 50.2% were current or former cigarette smokers. By histology, proportions of current or formers smokers ranged from 38% in patients with chromophobe carcinoma to 61.9% in those with collecting duct/medullary carcinoma. The aPRs (with the most common histology, clear cell RCC, as referent group) for current and former cigarette smoking among chromophobe RCC cases (4.9% of our analytic sample) were 0.58 [95% confidence interval (CI), 0.50-0.67] and 0.88 (95% CI, 0.81-0.95), respectively. Other aPRs were slightly increased (papillary RCC and unclassified RCC, current smoking only), slightly decreased (unclassified RCC, former smoking only), or not significantly different from 1.0 (collecting duct/medullary carcinoma and cyst-associated RCC). CONCLUSIONS: Compared with other RCC histologic types, chromophobe RCC has a weaker (if any) association with smoking. IMPACT: This study shows the value of population-based cancer registries' collection of smoking data, especially for epidemiologic investigation of rare cancers.

Postdiagnosis Body Mass Index, Weight Change, and Mortality From Prostate Cancer, Cardiovascular Disease, and All Causes Among Survivors of Nonmetastatic Prostate Cancer.

PURPOSE: To investigate the association of postdiagnosis body mass index (BMI) and weight change with prostate cancer-specific mortality (PCSM), cardiovascular disease-related mortality (CVDM), and all-cause mortality among survivors of nonmetastatic prostate cancer. METHODS: Men in the Cancer Prevention Study II Nutrition Cohort diagnosed with nonmetastatic prostate cancer between 1992 and 2013 were followed for mortality through December 2016. Current weight was self-reported on follow-up questionnaires approximately every 2 years. Postdiagnosis BMI was obtained from the first survey completed 1 to < 6 years after diagnosis. Weight change was the difference in weight between the first and second postdiagnosis surveys. Deaths occurring within 4 years of the follow-up were excluded to reduce bias from reverse causation. Analyses of BMI and weight change included 8,330 and 6,942 participants, respectively. RESULTS: Postdiagnosis BMI analyses included 3,855 deaths from all causes (PCSM, n = 500; CVDM, n = 1,155). Using Cox proportional hazards models, hazard ratios (HRs) associated with postdiagnosis obesity (BMI ≥ 30 kg/m2) compared with healthy weight (BMI 18.5 to < 25.0 kg/m2) were 1.28 for PCSM (95% CI, 0.96 to 1.67), 1.24 for CVDM (95% CI, 1.03 to 1.49), and 1.23 for all-cause mortality (95% CI, 1.11 to 1.35). Weight gain analyses included 2,973 deaths (PCSM, n = 375; CVDM, n = 881). Postdiagnosis weight gain (> 5% of body weight), compared with stable weight (± < 3%), was associated with a higher risk of PCSM (HR, 1.65; 95% CI, 1.21 to 2.25) and all-cause mortality (HR, 1.27; 95% CI, 1.12 to 1.45) but not CVDM. CONCLUSION: Results suggest that among survivors of nonmetastatic prostate cancer with largely localized disease, postdiagnosis obesity is associated with higher CVDM and all-cause mortality, and possibly higher PCSM, and that postdiagnosis weight gain may be associated with a higher mortality as a result of all causes and prostate cancer.

Red and Processed Meat, Poultry, Fish, and Egg Intakes and Cause-Specific and All-Cause Mortality among Men with Nonmetastatic Prostate Cancer in a U.S. Cohort.

BACKGROUND: Research on the relationship of meat, fish, and egg consumption and mortality among prostate cancer survivors is limited. METHODS: In the Cancer Prevention Study-II Nutrition Cohort, men diagnosed with nonmetastatic prostate cancer between baseline in 1992/1993 and 2015 were followed for mortality until 2016. Analyses of pre- and postdiagnosis intakes of red and processed meat, poultry, fish, and eggs included 9,286 and 4,882 survivors, respectively. Multivariable-adjusted RRs and 95% confidence intervals (CI) were estimated using Cox proportional hazards models. RESULTS: A total of 4,682 and 2,768 deaths occurred during follow-up in pre- and postdiagnosis analyses, respectively. Both pre- and postdiagnosis intakes of total red and processed meat were positively associated with all-cause mortality (quartile 4 vs. 1: RR = 1.13; 95% CI, 1.03-1.25; P trend = 0.02; RR = 1.22; 95% CI, 1.07-1.39; P trend = 0.03, respectively), and both pre- and postdiagnosis poultry intakes were inversely associated with all-cause mortality (quartile 4 vs. 1 RR = 0.90; 95% CI, 0.82-0.98; P trend = 0.04; RR = 0.84; 95% CI, 0.75-0.95; P trend = 0.01, respectively). No associations were seen for prostate cancer-specific mortality, except that higher postdiagnosis unprocessed red meat intake was associated with lower risk. CONCLUSIONS: Higher red and processed meat, and lower poultry, intakes either before or after prostate cancer diagnosis were associated with higher risk of all-cause mortality. IMPACT: Our findings provide additional evidence that prostate cancer survivors should follow the nutrition guidelines limiting red and processed meat consumption to improve overall survival. Additional research on the relationship of specific meat types and mortality is needed.

Epidemiologic risk factors for in situ and invasive ductal breast cancer among regularly screened postmenopausal women by grade in the Cancer Prevention Study-II Nutrition Cohort.

PURPOSE: Histopathologic grade provides an integrated measure of biologic features which affects cancer prognosis. In invasive ductal breast cancer (IDBC), the grade of the ductal carcinoma in situ (DCIS) and invasive components are usually concordant, suggesting grade is established early in tumorigenesis and may be linked to etiologic factors. In this study, we used prospectively collected data from postmenopausal women in the Cancer Prevention Study-II (CPS-II) Nutrition Cohort to compare risk factor associations among low-grade and high-grade DCIS, as well as low-grade and high-grade IDBC. METHODS: Among 73,825 cancer-free women at enrollment in the CPS-II Nutrition Cohort in 1992-1993 (mean age: 62.1 years), we verified 802 diagnosed with DCIS (C50 8500/2; n = 430 low-grade and 372 high-grade) and 3,125 with IDBC (C50 8500/3; n = 2,221 low-grade and 904 high-grade) through June 2013. Person-time contribution was conditional on screening mammograms self-reported on biennial surveys. Multivariable-adjusted joint Cox proportional hazards regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: A personal history of benign breast disease was more strongly associated with higher risk of low-grade DCIS (HR = 2.20, 95% CI 1.81-2.67; p for heterogeneity = 0.0004) than high-grade DCIS. Consumption of two or more alcoholic drinks/day was only associated with a higher risk of low-grade IDBC (HR = 1.58, 95% CI 1.33-1.88; p for heterogeneity = 0.005). CONCLUSIONS: These results suggest heterogeneity by grade for breast cancer etiology. Identification of potential risk factor differences among low-grade and high-grade DCIS and IDBC may help to clarify associations, and ultimately, improve breast cancer risk prediction models.

Prevalence and correlates of non-tissue prostate cancer diagnosis in the United States.

BACKGROUND: Given the potential complications of prostate biopsies, it is sometimes reasonable in selected patients to make a non-tissue diagnosis of prostate cancer. Little is known about prevalence and factors associated with non-tissue prostate cancer diagnoses in the United States. METHODS: We identified 40 to 99-year-old prostate cancer patients with prostate specific antigen (PSA) ≥20 ng/ml from the 2010-2015 National Cancer Database. Associations were examined between non-tissue prostate cancer diagnosis and age, race, clinical T (cT) and M (cM) categories, PSA, and Charlson-Deyo Comorbidity Index (CCI) with multivariable analyses. RESULTS: Among 62,635 patients, 6.2% had a non-tissue diagnosis. The proportion of patients with non-tissue diagnoses increased with advanced age (from 0.9% in ages 40-49 to 44.0% in ages 90-99) and disease stage (cT and cM) and higher CCI and PSA level. Demographic and clinical characteristics statistically significantly associated (all P < .001) with non-tissue diagnosis in adjusted analyses were older age (OR = 24.24, 90 to 99 vs. 60 to 69 years), and higher cT (OR = 4.83; T4 vs. T1), cM (OR = 5.25, M1C vs. M0), CCI (OR = 2.07; 3+ vs. 0), and PSA levels (OR = 3.19, >97.9 ng/ml vs.20 to 39 ng/ml), as well as hormonal therapy (OR = 0.51, with vs. without). CONCLUSIONS: Non-tissue diagnosis of prostate cancer, while rare, is not outside normal clinical practice and is strongly associated with advanced patient age, higher clinical stage, multiple comorbidities, and very high PSA levels.

Mode of detection and breast cancer mortality by follow-up time and tumor characteristics among screened women in Cancer Prevention Study-II.

PURPOSE: In a screened population, breast cancer-specific mortality is lower for screen-detected versus symptom-detected breast cancers; however, it is unclear whether this association varies by follow-up time and/or tumor characteristics. To further understand the prognostic utility of mode of detection, we examined its association with breast cancer-specific mortality, overall and by follow-up time, estrogen receptor status, tumor size, and grade. METHODS: In the Cancer Prevention Study-II Nutrition Cohort, 3975 routinely screened women were diagnosed with invasive breast cancer (1992-2015). Among 2686 screen-detected and 1289 symptom-detected breast cancers, 206 and 209 breast cancer deaths, respectively, occurred up to 24 years post diagnosis. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated from Cox proportional hazard regression models. RESULTS: Controlling for prognostic factors, symptom detection was associated with higher risk of breast cancer-specific death up to 5 years after diagnosis (HR≤5years = 1.88, 95% CI 1.21-2.91) this association was attenuated in subsequent follow-up (HR>5years = 1.26, 95% CI 0.98-1.63). Within tumor characteristic strata, there was a 1.3-2.7-fold higher risk of breast cancer death associated with symptom-detected cancers ≤ 5 years of follow-up, although associations were only significant for women with tumors < 2 cm (HR≤5years = 2.42, 95% CI 1.19-4.93) and for women with grade 1 or 2 tumors (HR≤5years = 2.72, 95% CI 1.33-5.57). In subsequent follow-up, associations were closer to the null. CONCLUSIONS: Screen detection is a powerful prognostic factor for short-term survival. Among women who survived at least 5 years after breast cancer diagnosis, other clinical factors may be more predictive of breast cancer survival.

Use of complementary/integrative methods: cancer survivors' misconceptions about recurrence prevention.

PURPOSE: Many cancer survivors use complementary and alternative health methods (CAM). Because we are unaware of high-level evidence supporting CAM for preventing cancer recurrence, we studied post-treatment survivors who use CAM to assess (1) the percentage who included preventing recurrence as a motive for using CAM, (2) characteristics of survivors who use CAM intended to prevent recurrence, and (3) CAM domains associated with use for recurrence prevention. METHODS: We studied participants in the American Cancer Society's Study of Cancer Survivors-I (nationwide study of adult survivors) who used CAM (excluding osteopathy, yoga, tai chi, or qi gong users, as well as anyone whose only reported CAM was prayer/meditation). Multivariable logistic regression was used to examine associations of independent variables with CAM use for recurrence prevention. RESULTS: Among 1220 survivors using CAM, 14.8% reported recurrence prevention as a reason for CAM use (although only 0.4% indicated this was their only reason). The following were independently associated with odds of CAM use to prevent recurrence: not being married/in a marriage-like relationship (OR = 1.53, 95% confidence interval [CI] 1.05-2.23), using mind-body (OR = 1.65, 95% CI 1.08-2.51) or biologically based (OR = 4.11, 95% CI 1.96-8.59) CAM and clinically relevant fear of recurrence (OR = 1.96, 95% CI 1.38-2.78). CONCLUSIONS: Approximately 1/7 of survivors who use CAM have unrealistic expectations about CAM reducing recurrence risk. This expectation is strongly associated with the use of biologically based CAM. IMPLICATIONS FOR CANCER SURVIVORS: Patient education should support informed decisions and realistic expectations regarding any complementary/integrative or mainstream/conventional clinical intervention.

Minimizing the burden of cancer in the United States: Goals for a high-performing health care system.

Between 1991 and 2015, the cancer mortality rate declined dramatically in the United States, reflecting improvements in cancer prevention, screening, treatment, and survivorship care. However, cancer outcomes in the United States vary substantially between populations defined by race/ethnicity, socioeconomic status, health insurance coverage, and geographic area of residence. Many potentially preventable cancer deaths occur in individuals who did not receive effective cancer prevention, screening, treatment, or survivorship care. At the same time, cancer care spending is large and growing, straining national, state, health insurance plans, and family budgets. Indeed, one of the most pressing issues in American medicine is how to ensure that all populations, in every community, derive the benefit from scientific research that has already been completed. Addressing these questions from the perspective of health care delivery is necessary to accelerate the decline in cancer mortality that began in the early 1990s. This article, part of the Cancer Control Blueprint series, describes challenges with the provision of care across the cancer control continuum in the United States. It also identifies goals for a high-performing health system that could reduce disparities and the burden of cancer by promoting the adoption of healthy lifestyles; access to a regular source of primary care; timely access to evidence-based care; patient-centeredness, including effective patient-provider communication; enhanced coordination and communication between providers, including primary care and specialty care providers; and affordability for patients, payers, and society.

A blueprint for cancer screening and early detection: Advancing screening's contribution to cancer control.

From the mid-20th century, accumulating evidence has supported the introduction of screening for cancers of the cervix, breast, colon and rectum, prostate (via shared decisions), and lung. The opportunity to detect and treat precursor lesions and invasive disease at a more favorable stage has contributed substantially to reduced incidence, morbidity, and mortality. However, as new discoveries portend advancements in technology and risk-based screening, we fail to fulfill the greatest potential of the existing technology, in terms of both full access among the target population and the delivery of state-of-the art care at each crucial step in the cascade of events that characterize successful cancer screening. There also is insufficient commitment to invest in the development of new technologies, incentivize the development of new ideas, and rapidly evaluate promising new technology. In this report, the authors summarize the status of cancer screening and propose a blueprint for the nation to further advance the contribution of screening to cancer control.

An assessment of progress in cancer control.

This article summarizes cancer mortality trends and disparities based on data from the National Center for Health Statistics. It is the first in a series of articles that will describe the American Cancer Society's vision for how cancer prevention, early detection, and treatment can be transformed to lower the cancer burden in the United States, and sets the stage for a national cancer control plan, or blueprint, for the American Cancer Society goals for reducing cancer mortality by the year 2035. Although steady progress in reducing cancer mortality has been made over the past few decades, it is clear that much more could, and should, be done to save lives through the comprehensive application of currently available evidence-based public health and clinical interventions to all segments of the population. CA Cancer J Clin 2018;000:000-000. © 2018 American Cancer Society.

Adequacy of Pathologic Reports of Invasive Breast Cancer From Mastectomy Specimens at Tikur Anbessa Specialized Hospital Oncology Center in Ethiopia.

Purpose Although information from pathology reports is essential to the care of individuals with cancer and to population-level cancer control, no systematic evidence exists regarding the adequacy of breast pathology reporting in Ethiopia. This study audited pathology reports of mastectomy specimens from patients evaluated at the Tikur Anbessa Specialized Hospital Oncology Center in Addis Ababa, Ethiopia. Methods Mastectomy pathology reports from February 2014 through January 2016 were assessed for gross and microscopic information considered by the Breast Cancer Initiative 2.5 (BCI 2.5; formerly the Breast Health Global Initiative) guideline to be necessary for care of patients with breast cancer stratified according to basic, limited, and enhanced resource settings. Results Fewer than two thirds (61.6%) of the 417 reports we reviewed included all four of the BCI 2.5 basic pathology data elements we could evaluate with available data (tumor category, lymph node category, histologic type, and histologic grade). Only 1.0% of reports included all three pathology data elements recommended for limited resource settings (estrogen receptor status, margin status, and lymphovascular invasion). Several elements were significantly more likely to be noted in reports from nonpublic hospitals than from public hospitals. Although only three of 417 reports included checklists or templates, all three of these reports included all of the basic pathology information, and they all included at least two of the three limited pathology elements not already on the basic list. Conclusion More than one third (38.4%) of mastectomy pathology reports did not meet BCI 2.5 standards for basic resource settings. Quality measurement and improvement programs and capacity-building interventions by national pathology and oncology organizations, collaboration with medical and public health organizations in neighboring countries, adoption of synoptic reporting templates, use of electronic pathology reporting, and histotechnology and histopathology training collaborations with laboratories in high-resource regions are recommended.

Smoking and Prostate Cancer-Specific Mortality after Diagnosis in a Large Prospective Cohort.

Background: Prior studies of prostate cancer survivors suggest that smoking might be associated with higher prostate cancer-specific mortality (PCSM) after diagnosis with prostate cancer. However, most of these studies were small, and questions remain regarding this association's strength and whether it persists after adjustment for stage and Gleason score.Methods: This analysis included men diagnosed with nonmetastatic prostate cancer between enrollment in the Cancer Prevention Study II Nutrition Cohort in 1992-1993 and June 2013. Cigarette smoking was self-reported at enrollment and updated in 1997 and every 2 years thereafter. Analyses of pre-diagnosis and post-diagnosis smoking included 9,781 and 9,111 prostate cancer cases, respectively, with vital status follow-up through 2014.Results: There were 672 deaths from prostate cancer in analyses of pre-diagnosis smoking and 554 in analyses of post-diagnosis smoking. In multivariable-adjusted Cox proportional hazards regression models including stage and Gleason score, both current smoking before diagnosis [HR = 1.50; 95% confidence interval (CI), 1.06-2.13] and current smoking after diagnosis (HR = 1.71; 95% CI, 1.09-2.67) were associated with higher PCSM compared to never smoking. Prostate cancer survivors who quit smoking <20 years before diagnosis were also at significantly higher risk of PCSM (HR = 1.29; 95% CI, 1.04-1.61).Conclusions: This large prospective study suggests that current smoking both before and after diagnosis of prostate cancer is associated with higher PCSM, even after accounting for stage and Gleason score.Impact: Our results provide evidence that smoking is a relevant prognostic factor for prostate cancer patients and that prostate cancer may be among the causes of death attributable to smoking. Cancer Epidemiol Biomarkers Prev; 27(6); 665-72. ©2018 AACR.

Recent Patterns in Shared Decision Making for Prostate-Specific Antigen Testing in the United States.

PURPOSE: Previous studies report infrequent use of shared decision making for prostate-specific antigen (PSA) testing. It is unknown whether this pattern has changed recently considering increased emphasis on shared decision making in prostate cancer screening recommendations. Thus, the objective of this study is to examine recent changes in shared decision making. METHODS: We conducted a retrospective cross-sectional study among men aged 50 years and older in the United States using 2010 and 2015 National Health Interview Survey (NHIS) data (n = 9,598). Changes in receipt of shared decision making were expressed as adjusted prevalence ratios (aPR) and 95% confidence intervals (CI). Analyses were stratified on PSA testing (recent [in the past year] or no testing). Elements of shared decision making assessed included the patient being informed about the advantages only, advantages and disadvantages, and full shared decision making (advantages, disadvantages, and uncertainties). RESULTS: Among men with recent PSA testing, 58.5% and 62.6% reported having received ≥1 element of shared decision making in 2010 and 2015, respectively (P = .054, aPR = 1.04; 95% CI, 0.98-1.11). Between 2010 and 2015, being told only about the advantages of PSA testing significantly declined (aPR = 0.82; 95% CI, 0.71-0.96) and full shared decision making prevalence significantly increased (aPR = 1.51; 95% CI, 1.28-1.79) in recently tested men. Among men without prior PSA testing, 10% reported ≥1 element of shared decision making, which did not change with time. CONCLUSION: Between 2010 and 2015, there was no increase in shared decision making among men with recent PSA testing though there was a shift away from only being told about the advantages of PSA testing towards full shared decision making. Many men receiving PSA testing did not receive shared decision making.

Trends in reporting histological subtyping of renal cell carcinoma: association with cancer center type.

Histological classification of renal cell carcinoma (RCC) has become increasingly important for clinical management. We identified 295483 RCC diagnosed from 1998-2014 in the National Cancer Database (NCDB) to examine temporal trends in proportions of RCC with unspecified histology and several specific histologies from the 1998 and 2004 World Health Organization classifications of RCC. Further, multivariable log binomial analysis of 101062 RCC diagnosed from 2010 to 2014 was used to determine whether the association of diagnosing/treating facility type and the proportion of unspecified RCC is independent of patient demographic and clinical factors. Between 1998 and 2014, the proportion of histologically unspecified RCC decreased substantially in all facility types, with the decrease smallest in community programs (from 86.0% to 28.1%) and largest in National Cancer Institute-designated centers (from 85.1% to 9.8%). These decreases were offset by increases in percentages of papillary, clear cell, and chromophobe RCC cases. During 2010 to 2014, relative to community programs, RCCs were 21% less likely to be reported as unspecified histology (adjusted prevalence ratio [aPR] = 0.79; 95% CI, 0.68-0.92) in comprehensive community programs, 32% less likely in integrated network programs (aPR = 0.68; 95% CI, 0.57-0.92) and academic programs (aPR = 0.68; 95% CI, 0.54-0.87), and 63% less likely (aPR = 0.37; 95% CI, 0.26-0.52) in National Cancer Institute -designated programs. These results have implications for the optimal selection of targeted systemic therapies for patients with advanced disease, and for the potential value of cancer registry data in pathology quality improvement programs to promote more rapid and consistent adoption of new classifications of RCC and other neoplasms.

Most Gleason 8 Biopsies are Downgraded at Prostatectomy-Does 4 + 4 = 7?

PURPOSE: Nonrepresentative biopsy sampling of prostate cancers with a biopsy Gleason score of 8 can adversely influence decisions regarding androgen deprivation in men receiving primary radiation therapy. The frequency of and factors associated with downgrading Gleason 8 biopsies at prostatectomy are not well known. MATERIALS AND METHODS: We used records from NCDB (National Cancer Database), a hospital based registry in the United States, of 72,556 men with prostate cancer diagnosed from 2010 to 2013, including 5,474 with Gleason 8 biopsies and no other high progression risk criteria according to NCCN (National Comprehensive Cancer Network®) Guidelines®. The prevalence of Gleason 8 downgrading was calculated. Generalized estimating equation multivariable regression models were used to estimate the prevalence ratios and 95% CIs of downgrading by demographic and clinical factors, and evaluate the association of Gleason 8 downgrading with cT (clinical T) to pathological T category up staging. RESULTS: Of 5,474 Gleason 8 biopsies in men lacking other high progression risk criteria 3,263 (60%) were downgraded, changing the progression risk category from high to intermediate. A higher prevalence of Gleason 8 downgrading was significantly and independently associated with decreasing age, African American race, lower cT category, lower prostate specific antigen quartile and certain combinations of primary and secondary Gleason grades (3 + 5 greater than 4 + 4 greater than 5 + 3). Gleason 8 downgrading in cases of cT less than 3 was independently and significantly associated with a lower prevalence of up staging (prevalence ratio = 0.65, 95% CI 0.61-0.69). CONCLUSIONS: Downgrading Gleason 8 biopsies is common. Patient evaluation based on Gleason 8 biopsies often results in overestimating progression risk and disease extent, which may lead to overtreatment.