Citations

Objective To evaluate survival among patients with urothelial carcinoma ( UC ) within the prostate in order to assess the impact of depth of tumour invasion as well as the importance of a concurrent bladder tumour. Patients and Methods We identified 201 patients who underwent radical cystectomy ( RC ) between 1980 and 2006 and were found to have UC involving the prostate. All specimens were re‐reviewed by a genitourinary pathologist. Survival was estimated using the K aplan– M eier method and compared with the log‐rank test. Cox hazard regression models tested the association of clinicopathological variables with outcome. Results In all, 93 patients had pTis disease in the prostate, 43 had pT2 tumours, and 66 patients were pT4a . The median follow‐up was 10.5 years. The 5‐year cancer‐specific survival for patients with pTis , pT2 , and pT4a prostate UC was 73%, 57%, and 21% respectively ( P < 0.001). On multivariable analysis, higher prostate tumour stage (hazard ratio [ HR ] 2.09; P = 0.01), positive lymph node status ( HR 2.09; P = 0.002), and concurrent ≥ pT3 bladder cancer ( HR 4.16; P < 0.001) were significantly associated with an increased risk of death from UC . Conclusions Among patients with prostatic UC involvement, depth of tumour invasion was significantly associated with cancer‐specific mortality, validating the staging reclassification. Concurrent locally advanced bladder cancer also negatively impacted survival, suggesting the potential prognostic value of reporting a secondary tumour stage in such cases.

Objective To assess recommendations for prostate‐specific antigen ( PSA ) screening in a national survey of radiation oncologists and urologists following the recent USA P reventive S ervices T ask F orce ( USPSTF ) grade D recommendation. Methods A random sample of 1366 radiation oncologists and urologists were identified from the A merican M edical A ssociation P hysician M asterfile. From N ovember 2011 to A pril 2012, a mail survey was sent to query PSA screening recommendations for men at average risk of prostate cancer for the following age groups: 40–49, 50–59, 60–69, 70–74, 75–79 and ≥80 years. Multivariable logistic regression was used to test for differences in PSA ‐based screening recommendations by physician characteristics. Results Response rates were similar at 52% for radiation oncologists and urologists ( P = 0.92). Overall, 51.5% of respondents recommended PSA ‐based screening for men aged 40–49 years, while nearly all endorsed it for those aged 50–74 years (96.1% for 50–59, 97.3% for 60–69, and 87.7% for 70–74 years). However, screening recommendations decreased to 43.9% and 12.8% for men aged 75–79 and ≥80 years, respectively. On multivariable analysis, urologists were more likely to recommend screening for men aged 40–49 (odds ratio [ OR ] 3.09; P < 0.001) and 50–59 years ( OR 3.81; P = 0.01), but less likely for men aged 75–79 ( OR 0.66; P = 0.01) and ≥80 years ( OR 0.45; P = 0.002) compared with radiation oncologists. Conclusion While radiation oncologists and urologists recommended PSA screening for men aged 50–69 years, there was less agreement about screening for younger (40–49 years old) and older (≥70 years) men at average risk for prostate cancer.

Objective To evaluate survival in patients after radical cystectomy ( RC ) who presented with non‐muscle‐invasive urothelial carcinoma and progressed to muscle invasion during surveillance. Our secondary objective was to evaluate the association between clinical factors before RC and survival. Patients and Methods In all, 981 consecutive M ayo C linic RC patients without a history of radiation or systemic chemotherapy were reviewed. Of these, 190 had RC after they progressed from non‐muscle invasive disease to muscle invasion (progressed to ≥ pT2 ). These patients were compared to 310 patients who had RC before muscle invasion (≤ pT1 ), and 481 patients who had muscle invasion at initial presentation (presented with ≥ pT2 ). Survival estimates were generated using the K aplan– M eier method and compared using the log‐rank test, while adjusted analyses were performed using C ox proportional hazard regression models. Results Patients who progressed to muscle invasion on surveillance had a higher risk of death than patients who initially presented with muscle invasion (overall survival hazard ratio [ HR ] 1.3; 95% confidence interval [ CI ] 1.0, 1.5). The estimated 5‐year cancer‐specific survival was 85.4% for patients presenting with ≤ pT1 , 52.9% for patients who progressed to ≥ pT2 , and 62.4% for patients who presented with ≥ pT2 ( P < 0.001). The corresponding 5‐year overall survival rates were 70.0%, 42.1%, and 49.5% ( P < 0.001). Of the patients who initially presented with non‐muscle‐invasive disease, progression to muscle invasion was associated with increased risk of cancer‐specific death (adjusted HR 2.38; 95% CI 1.6, 3.5). Lack of information about patients who presented without muscle invasion and never received RC is the major limitation of this study. Conclusions Despite close surveillance, many patients who progress to muscle invasion will die from bladder cancer. Patients who progress to muscle invasion on surveillance seem to have particularly aggressive disease and may benefit from multimodal treatments.

Objective To determine renal function eligibility for cisplatin‐based chemotherapy using our experience with radical cystectomy ( RC ) patients. Patients and Methods Using the M ayo C linic C ystectomy R egistry, we identified 768 patients treated with RC without neoadjuvant chemotherapy for urothelial carcinoma from 1980–2005. Glomerular filtration rate ( GFR ) was estimated using the C hronic K idney D isease E pidemiology C ollaboration ( CKD‐EPI ) equation and a value of ≥60 mL/min was considered eligible for cisplatin‐based chemotherapy. Factors associated with change in GFR (from preoperative to 3‐month postoperative) were assessed using linear regression. Results The median age was 68 years, while the median GFR was 60 mL/min both preoperatively and 3 months after RC . Overall, 405 (53%) patients had a GFR of <60 mL/min before surgery and 387 (50%) had a GFR of <60 mL/min at 3 months after RC . Patients with hydronephrosis (209 patients) had significantly lower preoperative GFRs than with patients without hydronephrosis (median 52 vs 62 mL/min, respectively; P < 0.001). Among the 363 patients with a GFR of ≥60 mL/min before RC , 91 (25%) had a decline in renal function to a GFR of <60 mL/min at 3 months after RC . In multivariable analyses, older age ( P < 0.001), higher preoperative GFR ( P < 0.001) and continent urinary diversion ( P = 0.011) were significantly associated with a negative change in GFR after RC . Conclusions Our results suggest that nearly half of patients undergoing RC are not eligible to receive perioperative cisplatin‐based chemotherapy based on renal function status. About a quarter of patients eligible for cisplatin before surgery are no longer eligible after RC . Certain patient characteristics and surgical factors are more likely to experience a negative change in GFR after RC and should be counselled accordingly.

What's known on the subject? and What does the study add? Variations in the type of urinary diversion exist for patients undergoing radical cystectomy. Although its use has been increasing from 2001 to 2008, patients who are older, female, and primary insured by Medicaid are less likely to receive continent diversions. Furthermore, patients treated surgically at high‐volume and teaching hospitals are more likely to receive continent diversions. Objective To describe the contemporary trends in urinary diversion among patients undergoing radical cystectomy ( RC ) for bladder cancer; and elucidate whether socioeconomic disparities persist in the type of diversion performed in the USA from a population‐based cohort. Patients and Methods Using the Nationwide Inpatient Sample, we identified patients who underwent RC for bladder cancer between 2001 and 2008. Multivariable regression models were used to identify patient and hospital covariates associated with continent urinary diversion and enumerate predicted probabilities for statistically significant variables over time. Results Overall, 55 635 (92%) patients undergoing RC for bladder cancer received incontinent urinary diversion, while 4552 (8%) patients received continent diversion from 2001 to 2008. Receipt of continent urinary diversion increased from 6.6% in 2001–2002 to 9.4% in 2007–2008 ( P < 0.001 for trend). Patients who were older (odds ratio [ OR ] 0.93; P < 0.001), female ( OR 0.52; P < 0.001) and insured by Medicaid ( OR 0.54; P = 0.002) were less likely to receive continent urinary diversion. However, patients treated at teaching ( OR 2.14; P < 0.001) and high‐volume hospitals ( OR 2.39; P = 0.04) had higher odds of continent urinary diversion. Predicted probabilities of continent diversion remained lower for female patients, Medicaid insurance status, and non‐teaching and medium/low‐volume hospitals over time. Conclusions In this nationally representative sample of hospitals from 2001 to 2008, the use of continent diversion in RC gradually increased. Although variations in urinary diversion exist by hospital teaching status, case volume, patient gender and primary health insurance, increased attention in expanding the use of continent diversions may help reduce these disparities for patients undergoing RC for bladder cancer.

ObjectivesTo examine the ability of standard and saturation transrectal prostate biopsy techniques to predict appropriate candidates for active surveillance.MethodsBetween 2005 and 2007, 500 consecutive patients underwent transrectal ultrasound‐guided biopsy by a standard template (12 cores) or saturation template (≥18 cores, median 27 cores), with subsequent radical prostatectomy. Using the criteria of Gleason score ≤6, clinical stage T1 or T2a, prostate‐specific antigen <10 and ≤33% of cores involved, 218 patients were potential candidates for active surveillance. Pathology results from the prostatectomy specimens were used to determine the accuracy of each biopsy technique. Biochemical failure after prostatectomy was evaluated using logistic and Cox proportional hazards regression.ResultsA standard biopsy was carried out for 124 patients and saturation biopsy for 94 patients. There was no statistically significant difference between the groups in terms of median age (P = 0.14), preoperative prostate‐specific antigen (P = 0.52) and clinical stage (P = 0.23). Similar rates of Gleason score ≥7 at the time of radical prostatectomy were found, with 14% for standard biopsy and 15% for saturation biopsy (P = 0.70). Upstaging was shown in two standard biopsy patients (1.6%) and no saturation biopsy patients (P = 0.62). A multivariate analysis adjusting for prior prostate biopsy, preoperative prostate‐specific antigen and clinical stage showed no difference in the rate of upgrading based on biopsy technique (P = 0.26). During follow up, 5‐year biochemical failure‐free survival estimates were not significantly different (P = 0.11).ConclusionsIn men with prostate cancer, standard and saturation transrectal prostate biopsies techniques are equally predictive of candidates for active surveillance.