"It Gives Me Peace of Mind So I Can Focus on Healing": Views on Advance Care Planning for Older Surgical Patients.

Introduction: The period of time before an elective operation may be an opportune time to engage older adults in advance care planning (ACP). Past interventions have not been readily incorporated into surgical workflows leaving a need for ACP tools that are generalizable, easy to implement, and effective. Design: This is a qualitative study. Setting and Subjects: Older adults with a history of cancer and a recent major operation were recruited through their surgical oncologist at a tertiary medical center in the United States. Interviews were conducted to determine how to adapt the validated PrepareForYourCare.org ACP program with electronic health record prompts for the perioperative setting and openness to introducing ACP during a presurgical visit. We used qualitative content analysis to determine themes. Results: Eight themes were identified: (1) ACP as static and private, (2) people expected a prompt, (3) family trusted to do the "right" thing, (4) lack of relationship or comfort with providers, (5) a team-based approach can be helpful, (6) surgeon's expertise (e.g., prognosis and surgical risk), (7) ACP belongs on the surgical checklist, and (8) patients would welcome a conversation starter. Discussion: Older surgical patients are interested in engaging with ACP, particularly if prompted, and believe it has a place on the preoperative "checklist." Conclusions: To effectively engage patients with ACP, a combination of routine prompts by the health care team and patient-centered follow-up may be required.

High-risk prostate cancer in the United States, 1990-2007.

OBJECTIVES: This study aimed to describe national trends in presentation, management, and outcomes for men with high risk prostate cancer. METHODS: Data were abstracted from CaPSURE; 10,808 men were diagnosed between 1990 and 2007 and had complete clinical data. High-risk was defined according to the D'Amico criteria; a more restrictive definition assigned clinical stage T2c to intermediate rather than high risk. Temporal trends were assessed for patient distribution among risk groups, and within the high-risk group for individual risk factors, Kattan nomogram score, Cancer of the Prostate Risk Assessment (CAPRA) score, and primary treatment. Survival analysis stratified by CAPRA score was performed. RESULTS: Under the standard definition, 31.2% of the men were diagnosed with high-risk disease, and 16.9% were high-risk under the restrictive definition. This proportion has fallen over time but has been stable since 2000. Patients who would be stratified to high risk under the standard definition and to intermediate risk under the restrictive definition have better outcomes than those stratified to either intermediate or high risk under both definitions. There has been no consistent risk migration within the high-risk group over time. Treatment varies substantially with CAPRA score within the high-risk group, with higher risk men less likely to receive local therapy. Use of androgen deprivation therapy has increased over time, both as primary therapy and in conjunction with both external beam radiation and brachytherapy. Biochemical outcomes vary according to CAPRA score within the high-risk group. CONCLUSIONS: Clinical stage T2c should not define high risk, and the high-risk group should be substratified using a multivariable instrument. There is no evidence for meaningful downward risk migration among high-risk patients over the past 15 years. At least some men in the high-risk group may be undertreated.

Contemporary trends in low risk prostate cancer: risk assessment and treatment.

PURPOSE: We updated national risk trends in prostate cancer with a focus on low risk tumors, reexamined trends in primary treatment for low risk tumors and substratified patients at low risk based on pretreatment clinical data. MATERIALS AND METHODS: Data were abstracted from the CaPSURE registry. A total of 10,385 men were diagnosed between 1990 and 2006 with localized disease. Low risk was defined as prostate specific antigen 10 ng/ml or less, Gleason score 6 or less and clinical T stage 2a or less. Temporal trends were assessed for patient distribution among risk groups and in the low risk group for individual risk factors, Kattan nomogram prediction, Cancer of the Prostate Risk Assessment score and primary treatment. The ability of the Cancer of the Prostate Risk Assessment score to substratify low risk prostatectomy cases was evaluated with survival analysis. RESULTS: The proportion of low risk tumors in CaPSURE almost doubled from 27.5% in 1990 to 1994, to 46.4% in 2000 to 2001 but it has been relatively constant since then. A growing proportion of low risk tumors are cT1c and virtually all are Gleason score 6. Prostate specific antigen and the percent of positive biopsies decreased throughout the study period, as did the mean Cancer of the Prostate Risk Assessment score. The use of active surveillance increased from a nadir of 6.2% in 2000 to 2001, to 10.2% in 2004 to 2006. The use of prostatectomy also increased, whereas the use of androgen deprivation and radiation decreased. The likelihood of recurrence increased significantly with increasing Cancer of the Prostate Risk Assessment scores. CONCLUSIONS: Patients at low risk can be further substratified to identify those at very low risk based on clinical variables. The use of surveillance is increasing but overtreatment remains a concern in these patients.