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Das S, Luu M, Terris M, Klaassen Z, Kane CJ, Amling C, Cooperberg M, Rivera LG, Aronson W, Freedland SJ, Daskivich TJ. Contemporary risk of biochemical recurrence after radical prostatectomy in the active surveillance era. Urol Oncol 2024; 42:175.e1-175.e8. [PMID: 38490923 DOI: 10.1016/j.urolonc.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/02/2024] [Accepted: 02/27/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVES To assess whether contemporary risks of biochemical recurrence (BCR) after radical prostatectomy (RP) in the AS era differ from historical estimates due to changes in tumor risk case mix and improvements in risk stratification. MATERIALS AND METHODS We sampled 6,682 men who underwent RP for clinically localized disease between 2000 and 2017 from the VA SEARCH database. Kaplan Meier analysis was used to calculate incidence of BCR before and after 2010 overall and within tumor risk subgroups. Multivariable Cox proportional hazard regression analysis including an interaction term between era and tumor risk was used to compare risk of BCR before and after 2010 overall and across tumor risk subgroups. RESULTS About 3,492 (52%) and 3,190 (48%) men underwent RP before and after 2010, respectively. In a limited multivariable model excluding tumor risk, overall BCR risk was higher post-2010 vs. pre-2010 (HR: 1.15, 95%CI: 1.05-1.25; 40% vs 36% at 8 years post-RP). However, this effect was eliminated after correcting for tumor risk (HR: 0.95, 95%CI: 0.87-1.04), suggesting that differences in tumor risk between eras mediated the change. Yet, within tumor-risk subgroups, BCR risk was significantly lower for favorable intermediate-risk (HR: 0.76, 95%CI:0.60-0.96) and unfavorable intermediate-risk PC (HR: 0.78, 95%CI: 0.67-0.90), but significantly higher for high-risk PC (HR: 1.22, 95%CI: 1.07-1.38) in the post-2010 era. 8-year risks of BCR in the post-2010 era were 21% (95%CI: 16%-25%), 25% (95%CI: 20%-30%), 41% (95%CI: 37%-46%), and 60% (95%CI: 56%-64%) for low-, FIR-, UIR-, and high-risk disease, respectively. Limitations include limited long-term follow-up in the post-2010 subgroup. CONCLUSIONS Overall BCR risk has increased in the AS era, driven by a higher risk case mix and increased BCR risk among high-risk patients. Physicians should quote contemporary estimates of BCR when counseling patients.
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Affiliation(s)
- Sanjay Das
- Durham Veterans Affairs Health Care System, Department of Surgery, Durham, NC; Department of Urology, University of California - Los Angeles, Los Angeles, CA; Department of Urology, Cedars-Sinai Medical Center, Los Angeles
| | - Michael Luu
- Department of Biostatistics and Bioinformatics, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Martha Terris
- Division of Urology, Charlie Norwood VA Medical Center, Augusta, GA; Department of Urology, Augusta University-Medical College of Georgia, Augusta, GA
| | - Zachary Klaassen
- Division of Urology, Charlie Norwood VA Medical Center, Augusta, GA; Department of Urology, Augusta University-Medical College of Georgia, Augusta, GA
| | | | | | - Matthew Cooperberg
- Department of Urology, University of California, San Francisco, CA; Section of Urology, San Francisco VA Medical Center, San Francisco, CA
| | - Lourdes Guerrios Rivera
- VA Caribbean Healthcare System, San Juan, PR; Department of Surgery, University of Puerto Rico, San Juan, PR
| | - William Aronson
- Department of Urology, University of California - Los Angeles, Los Angeles, CA; Greater Los Angeles Veterans Affairs, Los Angeles, CA
| | - Stephen J Freedland
- Durham Veterans Affairs Health Care System, Department of Surgery, Durham, NC; Department of Urology, Cedars-Sinai Medical Center, Los Angeles; Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Timothy J Daskivich
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles; Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA.
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Dirix P, Dal Pra A, Khoo V, Carrie C, Cozzarini C, Fonteyne V, Ghadjar P, Gomez-Iturriaga A, Schmidt-Hegemann NS, Panebianco V, Zapatero A, Bossi A, Wiegel T. ESTRO ACROP consensus recommendation on the target volume definition for radiation therapy of macroscopic prostate cancer recurrences after radical prostatectomy. Clin Transl Radiat Oncol 2023; 43:100684. [PMID: 37808453 PMCID: PMC10556584 DOI: 10.1016/j.ctro.2023.100684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 09/22/2023] [Indexed: 10/10/2023] Open
Abstract
Background The European Society for Radiotherapy & Oncology (ESTRO) Advisory Committee for Radiation Oncology Practice (ACROP) panel on prostate bed delineation reflected on macroscopic local recurrences in patients referred for postoperative radiotherapy (PORT), a challenging situation without standardized approach, and decided to propose a consensus recommendation on target volume selection and definition. Methods An ESTRO ACROP contouring consensus panel consisting of 12 radiation oncologists and one radiologist, all with subspecialty expertise in prostate cancer, was established. Participants were asked to delineate the prostate bed clinical target volumes (CTVs) in two separate clinically relevant scenarios: a local recurrence at the seminal vesicle bed and one apically at the level of the anastomosis. Both recurrences were prostate-specific membrane antigen (PSMA)-avid and had an anatomical correlate on magnetic resonance imaging (MRI). Participants also answered case-specific questionnaires addressing detailed recommendations on target delineation. Discussions via electronic mails and videoconferences for final editing and consensus were performed. Results Contouring of the two cases confirmed considerable variation among the panelists. Finally, however, a consensus recommendation could be agreed upon. Firstly, it was proposed to always delineate the entire prostate bed as clinical target volume and not the local recurrence alone. The panel judged the risk of further microscopic disease outside of the visible recurrence too high to safely exclude the rest of the prostate bed from the CTV. A focused, "stereotactic" approach should be reserved for re-irradiation after previous PORT. Secondly, the option of a focal boost on the recurrence was discussed. Conclusion Radiation oncologists are increasingly confronted with macroscopic local recurrences visible on imaging in patients referred for postoperative radiotherapy. It was recommended to always delineate and irradiate the entire prostate bed, and not the local recurrence alone, whatever the exact location of that recurrence. Secondly, specific dose-escalation on the macroscopic recurrence should only be considered if an anatomic correlate is visible. Such a focal boost is probably feasible, provided that OAR constraints are prioritized. Possible dose is also dependent on the location of the recurrence. Its potential benefit should urgently be investigated in prospective clinical trials.
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Affiliation(s)
- Piet Dirix
- Department of Radiation Oncology, Iridium Network, Antwerp, Belgium
| | - Alan Dal Pra
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, USA
- University of Bern, Bern University Hospital, Bern, Switzerland
| | - Vincent Khoo
- Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | | | - Cesare Cozzarini
- Department of Radiotherapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valérie Fonteyne
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium
| | - Pirus Ghadjar
- Department of Radiation Oncology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
| | - Alfonso Gomez-Iturriaga
- Radiation Oncology, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Barakaldo, Spain
| | | | - Valeria Panebianco
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - Almudena Zapatero
- Department of Radiation Oncology, La Princesa University Hospital, Health Reasearch Institute Princesa, Madrid, Spain
| | - Alberto Bossi
- Radiation Oncology, Centre Charlebourg, La Garenne Colombe, France
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
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Hashine K, Yamashita N, Tachou T, Kan M, Yanagaki T, Oka A, Takeda H, Shirato A, Watanabe U, Miura N, Saika T. Radical prostatectomy trends between 2010 and 2020 in Ehime, Japan, identified using data from the Medical Investigation Cancer Network (MICAN) study. Int J Urol 2023. [PMID: 36941084 DOI: 10.1111/iju.15178] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/21/2023] [Indexed: 03/22/2023]
Abstract
OBJECTIVES The use of radical prostatectomy is increasing with the rising incidence of prostate cancer. We assessed the surgical trends related to radical prostatectomy using data from a multi-center, retrospective cohort study, the MICAN (Medical Investigation Cancer Network) study, which was conducted in all the urology-related medical facilities in Ehime Prefecture, Japan. METHODS We compared data from the MICAN study with prostate biopsy registry data collected in Ehime between 2010 and 2020 and recorded the surgical trends. RESULTS There was a significant increase in the mean age of patients with positive biopsies, and the positivity rate increased from 46.3% in 2010 to 60.5% in 2020, while the number of biopsies obtained decreased. The number of radical prostatectomies performed increased over the years, with robot-assisted radical prostatectomy becoming the predominant procedure. In 2020, robot-assisted radical prostatectomies accounted for 96.0% of the surgeries performed. The age at surgery also gradually increased. Of the registered patients aged ≤75 years, 40.5% underwent surgery in 2010, compared with 83.1% in 2020. The prevalence of surgery also increased from 4.6% to 29.8% in patients aged >75 years. There was a gradual increase in the proportion of high-risk cases, from 29.3% to 44.0%, but a decrease in that of low-risk cases, from 23.8% in 2010 to 11.4% in 2020. CONCLUSIONS We have shown that the number of radical prostatectomies performed in Ehime is increasing in patients aged both ≤75 and >75 years. The proportion of low-risk cases has decreased, while that of high-risk cases has increased.
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Affiliation(s)
- Katsuyoshi Hashine
- Department of Urology, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
| | - Natsumi Yamashita
- Division of Clinical Biostatistics, Section of Cancer Prevention and Epidemiology, Clinical Research Center, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
| | - Takatoshi Tachou
- Department of Urology, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Masaharu Kan
- Department of Urology, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | | | - Akihiro Oka
- Department of Urology, Uwajima City Hospital, Uwajima, Japan
| | - Hajime Takeda
- Department of Urology, Yawatahama City General Hospital, Yawatahama, Japan
| | - Akitomi Shirato
- Department of Urology, Saiseikai Matsuyama Hospital, Matsuyama, Japan
| | - Uichi Watanabe
- Department of Urology, Jyuzen General Hospital, Niihama, Japan
| | | | - Takashi Saika
- Department of Urology, Ehime University, Toon, Japan
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Naser-Tavakolian A, Venkataramana A, Spiegel B, Almario C, Kokorowski P, Freedland SJ, Anger JT, Leppert JT, Daskivich TJ. The impact of life expectancy on cost-effectiveness of treatment options for clinically localized prostate cancer. Urol Oncol 2023; 41:205.e1-205.e10. [PMID: 36737259 DOI: 10.1016/j.urolonc.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/22/2022] [Accepted: 01/09/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Life expectancy (LE) impacts effectiveness and morbidity of prostate cancer (CaP) treatment, but its impact on cost-effectiveness is unknown. We sought to evaluate the impact of LE on the cost-effectiveness of radical prostatectomy (RP), radiation therapy (RT), and active surveillance (AS) for clinically localized disease. METHODS We created a Markov model to calculate incremental cost-effectiveness ratios (ICERs) for RP, RT, and AS over a 20-year time horizon from a Medicare payer perspective for low- and intermediate-risk CaP. Mortality outcomes varied by tumor risk and PCCI score, a validated proxy for LE. We performed 1,000 Monte Carlo simulations with 1-way sensitivity analyses of PCCI within each tumor risk subgroup to compare cost/quality-adjusted life years (QALYs) between treatments. RESULTS AS dominated RP and RT for low- and intermediate-risk disease in men with LE ≤10 years (PCCI ≥7 and ≥9, respectively). However, AS failed to dominate RP and RT for men with longer LE. For men with low-risk cancer and LE>10 years (PCCI 0-6), AS had the greatest effectiveness, but failed to dominate due to higher cost relative to RP. For men with intermediate-risk cancer with LE>10 years, AS failed to dominate due to higher cost relative to RP (PCCI 0-8) and lower effectiveness relative to RT (PCCI 0-3). The range of QALYs between RP, RT, and AS varied <13% (range: 0%-12.9%) while costs varied up to 521% (range 0.5%-521%) across PCCI scores. CONCLUSIONS LE strongly modulates the cost of CaP treatments. This results in AS dominating RP and RT in men with LE ≤10 years. However, in men with longer LE, AS fails to dominate primarily due to its high cumulative costs, underscoring the need for risk-adjusted AS protocols.
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Affiliation(s)
| | - Abhishek Venkataramana
- The Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Brennan Spiegel
- Cedars-Sinai Center for Outcomes Research and Education, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Christopher Almario
- Cedars-Sinai Center for Outcomes Research and Education, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Paul Kokorowski
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephen J Freedland
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA; Section of Urology, Durham VA Medical Center, Durham, NC
| | | | | | - Timothy J Daskivich
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA; Cedars-Sinai Center for Outcomes Research and Education, Cedars-Sinai Medical Center, Los Angeles, CA.
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Cao C, Zhang C, Sriskandarajah C, Xu T, Gotto G, Sutcliffe S, Yang L. Trends and Racial Disparities in the Prevalence of Urinary Incontinence Among Men in the USA, 2001-2020. Eur Urol Focus 2022; 8:1758-1767. [PMID: 35562253 DOI: 10.1016/j.euf.2022.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/09/2022] [Accepted: 04/26/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Male urinary incontinence (UI) affects quality of life and leads to a significant burden to the health care system. However, the contemporary prevalence and recent trends in UI and its subtypes among US men remain unknown. OBJECTIVE We evaluated 20-yr trends in the prevalence of UI and its subtype in US men aged ≥20 yr. DESIGN, SETTING, AND PARTICIPANTS A serial, cross-sectional analysis of the US nationally representative data from the National Health and Nutrition Examination Survey among men from 2001 to 2020. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Prevalence of any, stress, urgency and overflow UI were derived. The frequency of UI was assessed in four categories: less than one time per month, a few times per month, a few times per week, and every day and/or night. All analyses were conducted using sample weights, stratification, and clustering of the complex sampling design. Sociodemographic and lifestyle correlates of UI over time were identified using multivariable logistic regressions. RESULTS AND LIMITATIONS Data on 22994 US men (mean age, 46.6 yr [standard error, 0.20]; weighted population, 848642150) were analyzed. The prevalence of any UI increased from 2001-2002 (11.5% [95% confidence interval {CI}, 10.0-13.0]) to 2017-2020 (19.3% [95% CI, 17.2-21.3]), driven by urgency (from 9.0% [95% CI, 7.5-10.4]) to 15.2% [95% CI, 13.4-16.9]) and overflow UI (from 3.3% [95% CI, 2.7-4.0] to 5.5% [95% CI, 4.5-6.4]; all p for trend < 0.01). UI affects 38.5% US men ≥60 yr of age, with increasing trends in urgency and overflow UI and a decreasing trend in stress UI (all p for trend < 0.05). Racial/ethnic disparities were noted, with patterns differed by UI subtype. Compared with non-Hispanic White, non-Hispanic Black men were more likely to report urgency UI (odds ratio [OR], 1.94 [95% CI, 1.71-2.20]). Hispanic men were more likely to report urgency UI (OR, 1.33 [95% CI, 1.14-1.56]), but less likely to report stress (OR, 0.74 [95% CI, 0.56-0.98]) and overflow (OR, 0.75 [95% CI, 0.58-0.98]) UI. Men with higher body mass index and current smokers were more likely to report any, stress, and urgency UI than their counterparts. A higher prevalence of any UI was found in men with low family poverty ratios and chronic diseases, and those who were physically inactive. CONCLUSIONS From 2001 to 2020, the overall prevalence of UI increased among US men, particularly for urgency and overflow UI. PATIENT SUMMARY In this report, we looked at the prevalence of urinary incontinence among US men in a nationally representative sample. We found that urinary incontinence increased in the past 20 yr driving by the urgency and overflow urinary incontinence.
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Affiliation(s)
- Chao Cao
- Program in Physical Therapy, Washington University School of Medicine, St Louis, MO, USA; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Christie Zhang
- Department of Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, Canada
| | - Cynthia Sriskandarajah
- Department of Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, Canada
| | - Tianlin Xu
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Geoffrey Gotto
- Southern Alberta Institute of Urology and Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Siobhan Sutcliffe
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO, USA; Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, MO, USA
| | - Lin Yang
- Department of Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, Canada; Departments of Oncology and Community Health Sciences, University of Calgary, Calgary, Canada.
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Daskivich TJ, Gale R, Luu M, Naser-Tavakolian A, Venkataramana A, Khodyakov D, Anger JT, Posadas E, Sandler H, Spiegel B, Freedland SJ. Variation in Communication of Competing Risks of Mortality in Prostate Cancer Treatment Consultations. J Urol 2022; 208:301-308. [PMID: 35377775 PMCID: PMC11070128 DOI: 10.1097/ju.0000000000002675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Men with prostate cancer prefer patient-specific, quantitative assessments of longevity in shared decision making. We sought to characterize how physicians communicate the 3 components of competing risks-life expectancy (LE), cancer prognosis and treatment-related survival benefit-in treatment consultations. MATERIALS AND METHODS Conversation related to LE, cancer prognosis and treatment-related survival benefit was identified in transcripts from treatment consultations of 42 men with low- and intermediate-risk disease across 10 multidisciplinary providers. Consensus of qualitative coding by multiple reviewers noted the most detailed mode of communication used to describe each throughout the consultation. RESULTS Physicians frequently failed to provide patient-specific, quantitative estimates of LE and cancer mortality. LE was omitted in 17% of consultations, expressed as a generalization (eg "long"/"short") in 17%, rough number of years in 31%, probability of mortality/survival at an arbitrary timepoint in 17% and in only 19% as a specific number of years. Cancer mortality was omitted in 24% of consultations, expressed as a generalization in 7%, years of expected life in 2%, probability at no/arbitrary timepoint in 40% and in only 26% as the probability at LE. Treatment-related survival benefit was often omitted; cancer mortality was reported without treatment in 38%, with treatment in 10% and in only 29% both with and without treatment. Physicians achieved "trifecta"-1) quantifying probability of cancer mortality 2) with and without treatment 3) at the patient's LE-in only 14% of consultations. CONCLUSIONS Physicians often fail to adequately quantify competing risks. We recommend the "trifecta" approach, reporting 1) probability of cancer mortality 2) with and without treatment 3) at the patient's LE.
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Affiliation(s)
- Timothy J. Daskivich
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Rebecca Gale
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michael Luu
- Department of Biostatistics, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Abhi Venkataramana
- Department of Urology, University of Southern California, Los Angeles, CA
| | | | - Jennifer T. Anger
- Department of Urology, University of California, San Diego, San Diego, CA
| | - Edwin Posadas
- Department of Medicine, Division of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Howard Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Brennan Spiegel
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA
- Department of Medicine, Divisions of Gastroenterology and Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephen J. Freedland
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
- Section of Urology, Durham VA Medical Center, Durham, NC
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Daskivich TJ, Gale R, Luu M, Khodyakov D, Anger JT, Freedland SJ, Spiegel B. Patient Preferences for Communication of Life Expectancy in Prostate Cancer Treatment Consultations. JAMA Surg 2021; 157:70-72. [PMID: 34757389 DOI: 10.1001/jamasurg.2021.5803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Timothy J Daskivich
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, California
| | - Rebecca Gale
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Luu
- Department of Biostatistics, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Jennifer T Anger
- Department of Urology, University of California, San Diego, San Diego
| | - Stephen J Freedland
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Brennan Spiegel
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, California.,Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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