Total Medicare Costs Associated With Diagnosis and Treatment of Prostate Cancer in Elderly Men

Organ-confined prostate cancer with negative surgical margins in an entirely-embedded radical prostatectomy is essentially non-lethal-a retrospective single-institutional study of 520 patients

PURPOSE

There is no risk-based stratification in serum PSA monitoring in prostate cancer (PCa) patients following radical prostatectomy (RP). Those patients with minimal risk of recurrence may be subjected to unnecessarily rigorous monitoring as well as to increased anxiety disproportionate to their actual prognosis. This study aimed to investigate outcomes in PCa patients with favorable pathologic parameters to see whether they can be followed less rigorously than current practice recommendations dictate.

METHODS

520 consecutive entirely embedded organ-confined RPs with negative margins and undetectable initial postoperative serum PSA at the University of Chicago Medical Center between 2005 and 2017 were retrospectively identified. Clinicopathologic parameters and follow-up data including serum PSA were analyzed.

RESULTS

No patients, regardless of their grade group (GG), developed metastasis or succumbed to a PCa-specific death. These patients had a median postoperative follow-up of 109 months. 2.2% (22/520) of the patients developed biochemical recurrence (BCR). There were 163, 279, 69, 4, and 5 RPs from GG 1 to 5, respectively. Of these, 0% (0/163), 1.8% (5/279), 18.8% (13/69), 0% (0/4), and 60% (3/5) developed BCR, sequentially.

CONCLUSION

In this study, organ-confined PCa with negative margins in an entirely embedded RP carried no mortality risk. In particular, the patients with GG 1-2 disease may have benefited from less rigorous monitoring. Additionally, enhanced patient reassurance could play a role in reducing anxiety in this subset of patients.

Development and validation of a predictive score for diagnosing prostate cancer in primary care

BACKGROUND

Prostate cancer (PCa) represents the fifth cause of death in the male population worldwide. The prostate-specific antigen (PSA) test demonstrated poor accuracy to assess the presence of PCa. Thus, the PSA testing paradigm should be moved from the systematic screening approach to the early identification of men who are harbouring clinically significant disease. Accurate clinical-based tools to predict PCa should therefore be developed for general practice. We derived and validated a PCa predictive score using a primary care data source.

METHODS

Using the Italian Health Search Database, we formed a cohort of men aged 45-90 years in the period between 2002 and 2015. These patients were followed up until 31 December 2022. Those with less than a 5-year follow-up were excluded. The cohort was randomly divided into 'derivation' and 'validation' samples in a 1:1 ratio. Along with the demographic and clinical determinants forming the score, we investigated the role of PSA kinetics in the prediction accuracy.

RESULTS

In a cohort of 529,082 men aged 45+ years, we identified 14,524 cases of PCa (incidence rate = 2.71 per 1000 person-years; 95% confidence interval = 2.67-2.80). The prediction accuracy of the PCa-HScore featured an explained variation of 12% and a discrimination power of 70%. The calibration slope was almost equal to 1 (p = 0.951, tested for equivalence against the 'perfect' slope) and the PSA kinetics did not improve the prediction accuracy.

CONCLUSIONS

The PCa-HScore might guide the prescription of PSA and/or other clinical strategies in those men reporting certain levels of risk. A related decision support system could therefore be implemented in primary care.

Association Between Hospital Efficiency and Quality of Care Among Fee-for-Service Medicare Beneficiaries with Prostate Cancer: A Retrospective Cohort Study

BACKGROUND

Technical efficiency evaluates a hospital's economic performance and plays an important role in variations in quality of care and outcomes. The study objective was to examine the association between hospital efficiency and quality of care among fee-for-service Medicare beneficiaries with prostate cancer and to assess if race moderates this association.

DESIGN

Retrospective study using Surveillance, Epidemiological, and End Results-Medicare (SEER-Medicare) data from 1998 to 2016 for prostate cancer patients aged ≥ 66. We computed hospital technical efficiency using a data envelopment analysis. Outcomes were emergency room visits, hospitalizations, cost, and mortality (all-cause and prostate cancer-specific). We used competing risk regression for survival, log-link GLM models for cost, and Poisson models for count data. The propensity score approach was used to minimize selection bias.

RESULTS

The cohort consisted of 323,325 patients. Compared to higher efficiency hospitals (upper quartile), low hospital efficiency (i.e., lower quartile) was associated with a higher hazard of long-term mortality (Hazard ratio (HR) = 1.06, 95% CI = 1.05, 1.08) and long-term prostate cancer-specific mortality (HR = 1.14, 95% CI = 1.11, 1.17). Compared to higher efficiency levels, lower levels were associated with impaired emergency room visits, hospitalizations, and costs. A one unit increase in the efficiency score was associated with greater benefits for cost and mortality for African American and white patients. The benefit was larger for African American patients compared to white patients.

CONCLUSIONS

Increasing hospital efficiency may help improve outcomes among Medicare prostate cancer patients. Policies to redirect patients to hospitals with higher efficiency can enhance the quality of care and outcomes.

Real-world utilization, patient characteristics, and treatment patterns among men with localized prostate cancer tested with the 17-gene genomic prostate score® (GPSTM) assay

OBJECTIVES

Descriptive study focusing on real-world utilization and characteristics of men with prostate cancer tested with the 17-gene Genomic Prostate Score® (GPS™) assay by linking administrative claims and electronic health record (EHR) data with GPS results.

METHODS

This retrospective, observational cohort study (January 1, 2013 to December 31, 2020) included men aged 40-80 years with localized prostate cancer claims, continuous enrollment in Optum's Integrated Claims data set, ≥1 day of EHR clinical activity, and a GPS result. Men were classified as undergoing definitive therapy (DT) (prostatectomy, radiation, or focal therapy) or active surveillance (AS). AS and DT distribution were analyzed across GPS results, National Comprehensive Cancer Network® (NCCN®) risk, and race. Costs were assessed 6 months after the first GPS result (index); clinical outcomes and AS persistence were assessed during the variable follow-up. All variables were analyzed descriptively.

RESULTS

Of 834 men, 650 (77.9%) underwent AS and 184 (22.1%) DT. Most men had Quan-Charlson comorbidity scores of 1-2 and a tumor stage of T1c (index). The most common Gleason patterns were 3 + 3 (79.6%) (AS cohort) and 3 + 4 (55.9%) (DT cohort). The mean (standard deviation) GPS results at index were 23.2 (11.3) (AS) and 30.9 (12.9) (DT). AS decreased with increasing GPS result and NCCN risk. Differences between races were minimal. Total costs were substantially higher in the DT cohort.

CONCLUSIONS

Most men with GPS-tested localized prostate cancer underwent AS, indicating the GPS result can inform clinical management. Decreasing AS with increasing GPS result and NCCN risk suggests the GPS complements NCCN risk stratification.

Association of race/ethnicity and patient care experiences with healthcare utilization and healthcare costs among prostate cancer survivors: A SEER-CAHPS study

INTRODUCTION

This study aimed to evaluate the association of race/ethnicity and patient care experiences (PCEs) with healthcare utilization and costs among US older adults with prostate cancer (PCa).

MATERIALS AND METHODS

The study used data from 2007 to 2015 Surveillance, Epidemiology, and End Results dataset linked to Medicare Consumer Assessment of Healthcare Providers and Systems survey and Medicare claims (SEER-CAHPS). We identified males aged ≥65 years who completed a CAHPS survey within 6-60 months post-PCa diagnosis. Covariate-adjusted associations of six CAHPS PCE composite measures with any emergency department visit and any inpatient stay (using logistic regressions), and with total part A and part B Medicare costs (using generalized linear models) were examined by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian, and other).

RESULTS

Among 1834 PCa survivors, a 1-point higher score for getting care quickly was associated with higher odds (odds ratio 1.08; 95% confidence interval [CI]: 1.02-1.15; p = 0.009) of any inpatient stay in Hispanic patients. Higher total costs were associated with a 1-point higher score for getting needed care among Hispanic patients ($590.84; 95% CI: $262.15, $919.53; p < 0.001); a 1-point higher score for getting care quickly among Hispanic patients ($405.26; 95% CI: $215.83, $594.69; p < 0.001); and a 1-point higher score for customer service among patients belonging to other races ($361.69; 95% CI: $15.68, $707.69; p = 0.04).

DISCUSSION

We observed differential associations by race/ethnicity between PCEs and healthcare utilization and costs. Further research is needed to explore the causes of these associations.

National Trends in Management of Newly Diagnosed Prostate Cancer

BACKGROUND

Deciding whether to treat or conservatively manage patients with prostate cancer is challenging. Recent changes in guidelines, advances in treatment technologies, and policy can influence decision making surrounding management, particularly for those for whom the decision to treat is discretionary. Contemporary trends in management of newly diagnosed prostate cancer are unclear.

METHODS

Using national Medicare data, men with newly diagnosed prostate cancer were identified between 2014 and 2019. Patients were classified by 5- and 10-year noncancer mortality risk. Multinomial logistic regression models were fit to assess adjusted trends in management over time. The primary outcome was management of prostate cancer: local treatment (inclusive of surgery, radiation, brachytherapy, or cryotherapy), hormone therapy, or observation.

RESULTS

Local treatment was the most common form of management and stable across years (68%). Use of observation increased (21%-23%, P < .001) and use of hormone therapy decreased (11%-8%, P < 0.001). After stratifying by 10-year non-cancer mortality risk, observation increased among men with low (22.3%-26.1%, P < .001) and moderate (19.9%-23.5%, P < .001) mortality risk. Conversely, use of treatment increased among those with high (62.8%-68.0%, P = .004) and very high (45.5%-54.1%, P < .001) risk of noncancer mortality. These trends were similar across groups when stratified by 5-year noncancer mortality risk.

CONCLUSION

Nationally, use of local treatment remains common and was stable throughout the study period. However, while local treatment declined among men with a lower risk of noncancer mortality, it increased among men with a higher risk of non-cancer mortality.

Longitudinal varying coefficient single-index model with censored covariates

It is of interest to health policy research to estimate the population-averaged longitudinal medical cost trajectory from initial cancer diagnosis to death, and understand how the trajectory curve is affected by patient characteristics. This research question leads to a number of statistical challenges because the longitudinal cost data are often non-normally distributed with skewness, zero-inflation, and heteroscedasticity. The trajectory is nonlinear, and its length and shape depend on survival, which are subject to censoring. Modeling the association between multiple patient characteristics and nonlinear cost trajectory curves of varying lengths should take into consideration parsimony, flexibility, and interpretation. We propose a novel longitudinal varying coefficient single-index model. Multiple patient characteristics are summarized in a single-index, representing a patient's overall propensity for healthcare use. The effects of this index on various segments of the cost trajectory depend on both time and survival, which is flexibly modeled by a bivariate varying coefficient function. The model is estimated by generalized estimating equations with an extended marginal mean structure to accommodate censored survival time as a covariate. We established the pointwise confidence interval of the varying coefficient and a test for the covariate effect. The numerical performance was extensively studied in simulations. We applied the proposed methodology to medical cost data of prostate cancer patients from the Surveillance, Epidemiology, and End Results-Medicare-Linked Database.

A current role status of micro-ultrasound imaging in prostate cancer diagnosis

 Recently diagnostic field in medicine was enriched by advances in ultrasonography (US) technology, which led to establishment of novel modalities, one of which is micro-ultrasound. Results demonstrated by early studies have been promising, simultaneously rising a question if those new modalities could become an alternative in diagnosis of prostatic carcinoma (PCa). To answer this question, several studies have been conducted where micro-ultrasound have been compared to standard diagnostic tools, such as conventional TRUS or mpMRI. Nevertheless, new technology presents with some limitations, which include inconsistent results, necessity for specialized equipment, need of training for investigators to understand the findings, and external validation. In this publication, we have identified studies that provided evaluation of the accuracy and efficiency of the micro-ultrasound technology. Additionally, analysis of the results provided a better understanding of the novel imaging tool when compared standard modalities in diagnosis of PCa. Increasing number of studies demonstrated that micro-ultrasound carries high detection rate of PCa and clinically significant prostatic cancer (csPCa), suggesting a similar performance to mpMRI and even showing superiority over conventional TRUS. Recent studies have also showed that micro-ultrasound takes active role in improving the detection of csPCa and guidance for prostate biopsy (PBx) as well as further treatment. Moreover, certain practical aspects such as lower costs, decreased waiting time, real-time imaging and application of the imaging tool for patients that are not suitable for mpMRI (contrast allergy, prosthetics etc.) are significant advantages. Analysis of the results still does not provide clear answer whether micro-ultrasound outperforms mpMRI. Further studies are necessary in order to completely understand the potential of this new technology.

Cost-Effectiveness of Annual Prostate MRI and Potential MRI-Guided Biopsy After Prostate-Specific Antigen Test Results

Importance

Magnetic resonance imaging (MRI) and potential MRI-guided biopsy enable enhanced identification of clinically significant prostate cancer. Despite proven efficacy, MRI and potential MRI-guided biopsy remain costly, and there is limited evidence regarding the cost-effectiveness of this approach in general and for different prostate-specific antigen (PSA) strata.

Objective

To examine the cost-effectiveness of integrating annual MRI and potential MRI-guided biopsy as part of clinical decision-making for men after being screened for prostate cancer compared with standard biopsy.

Design, Setting, and Participants

Using a decision analytic Markov cohort model, an economic evaluation was conducted projecting outcomes over 10 years for a hypothetical cohort of 65-year-old men in the US with 4 different PSA strata (<2.5 ng/mL, 2.5-4.0 ng/mL, 4.1-10.0 ng/mL, >10 ng/mL) identified by screening through Monte Carlo microsimulation with 10 000 trials. Model inputs for probabilities, costs in 2020 US dollars, and quality-adjusted life-years (QALYs) were from the literature and expert consultation. The model was specifically designed to reflect the US health care system, adopting a federal payer perspective (ie, Medicare).

Exposures

Magnetic resonance imaging with potential MRI-guided biopsy and standard biopsy.

Main Outcomes and Measures

Incremental cost-effectiveness ratios (ICERs) using a willingness-to-pay threshold of $100 000 per QALY was estimated. One-way and probabilistic sensitivity analyses were performed.

Results

For the 3 PSA strata of 2.5 ng/mL or greater, the MRI and potential MRI-guided biopsy strategy was cost-effective compared with standard biopsy (PSA 2.5-4.0 ng/mL: base-case ICER, $21 131/QALY; PSA 4.1-10.0 ng/mL: base-case ICER, $12 336/QALY; PSA >10.0 ng/mL: base-case ICER, $6000/QALY). Results varied depending on the diagnostic accuracy of MRI and potential MRI-guided biopsy. Results of probabilistic sensitivity analyses showed that the MRI and potential MRI-guided biopsy strategy was cost-effective at the willingness-to-pay threshold of $100 000 per QALY in a range between 76% and 81% of simulations for each of the 3 PSA strata of 2.5 ng/mL or more.

Conclusions and Relevance

This economic evaluation of a hypothetical cohort suggests that an annual MRI and potential MRI-guided biopsy was a cost-effective option from a US federal payer perspective compared with standard biopsy for newly eligible male Medicare beneficiaries with a serum PSA level of 2.5 ng/mL or more.

Cardiovascular mortality by cancer risk stratification in patients with localized prostate cancer: a SEER-based study

Purpose

The risk of cardiovascular disease (CVD) mortality in patients with localized prostate cancer (PCa) by risk stratification remains unclear. The aim of this study was to determine the risk of CVD death in patients with localized PCa by risk stratification.

Patients and methods

Population-based study of 340,806 cases in the Surveillance, Epidemiology, and End Results (SEER) database diagnosed with localized PCa between 2004 and 2016. The proportion of deaths identifies the primary cause of death, the competing risk model identifies the interaction between CVD and PCa, and the standardized mortality rate (SMR) quantifies the risk of CVD death in patients with PCa.

Results

CVD-related death was the leading cause of death in patients with localized PCa, and cumulative CVD-related death also surpassed PCa almost as soon as PCa was diagnosed in the low- and intermediate-risk groups. However, in the high-risk group, CVD surpassed PCa approximately 90 months later. Patients with localized PCa have a higher risk of CVD-related death compared to the general population and the risk increases steadily with survival (SMR = 4.8, 95% CI 4.6-5.1 to SMR = 13.6, 95% CI 12.8-14.5).

Conclusions

CVD-related death is a major competing risk in patients with localized PCa, and cumulative CVD mortality increases steadily with survival time and exceeds PCa in all three stratifications (low, intermediate, and high risk). Patients with localized PCa have a higher CVD-related death than the general population. Management of patients with localized PCa requires attention to both the primary cancer and CVD.

Outcomes of dose-escalated IMRT and ADT in Octogenarians with prostate cancer

INTRODUCTION

We evaluated long-term outcomes for octogenarians with localised prostate cancer treated using dose-escalated image-guided intensity-modulated radiation therapy (IMRT) at our institution.

METHODS

The charts of octogenarians treated for localised prostate cancer were retrospectively reviewed. Overall survival (OS), prostate cancer-specific survival (PCaSS), toxicity rates and changes from baseline were collected.

RESULTS

The median follow-up was 97 months. Of 107 eligible patients, 27.1% had intermediate-risk and 72.9% had high-risk localised prostate cancer. Median dose was 78Gy, and 97.2% received ADT. OS was 91.4% and 67.2% at 5 and 10 years. PCaSS was 98.0% and 88.7% at 5 and 10 years. In all, 39 (36.4%) of patients died, with the cause of death known in 30: in 26.7% of these patients, prostate cancer was the cause of death. Grade ≥ 2 late GI and GU toxicity was 0.9% and 24.3% respectively. In all, 11.2% and 22.4% of patients reported worsening of GI or GU function from baseline, and 13.1% and 21.5% reported improvement in GI and GU function compared to baseline.

CONCLUSION

Selected octogenarian patients with localised prostate cancer appear to benefit from radiation therapy and ADT. Despite excellent long-term PCaSS, 26.7% of patients died of prostate cancer. Rates of GI and GU toxicity were acceptable, and deterioration of urinary and bowel function compared to baseline was just as common as improvement in function from baseline.

Complex implementation factors demonstrated when evaluating cost-effectiveness and monitoring racial disparities associated with [18F]DCFPyL PET/CT in prostate cancer men

Prostate cancer (PC) staging with conventional imaging often includes multiparametric magnetic resonance (MR) of the prostate, computed tomography (CT) of the chest, abdomen, and pelvis, and whole-body bone scintigraphy. The recent development of highly sensitive and specific prostate specific membrane antigen (PSMA) positron emission tomography (PET) has suggested that prior imaging techniques may be insufficiently sensitive or specific, particularly when evaluating small pathologic lesions. As PSMA PET/CT is considered to be superior for multiple clinical indications, it is being deployed as the new multidisciplinary standard-of-care. Given this, we performed a cost-effectiveness analysis of [¹⁸F]DCFPyL PSMA PET/CT imaging in the evaluation of PC relative to conventional imaging and anti-3-[¹⁸F]FACBC (¹⁸F-Fluciclovine) PET/CT. We also conducted a single institution review of PSMA PET/CT scans performed primarily for research indications from January 2018 to October 2021. Our snapshot of this period of time in our catchment demonstrated that PSMA PET/CT imaging was disproportionately accessed by men of European ancestry (EA) and those residing in zip codes associated with a higher median household income. The cost-effectiveness analysis demonstrated that [¹⁸F]DCFPyL PET/CT should be considered as an alternative to anti-3-[¹⁸F]FACBC PET/CT and standard of care imaging for prostate cancer staging. [¹⁸F]DCFPyL PET/CT is a new imaging modality to evaluate PC patients with higher sensitivity and specificity in detecting disease than other prostate specific imaging studies. Despite this, access may be inequitable. This discrepancy will need to be addressed proactively as the distribution network of the radiotracer includes both academic and non-academic sites nationwide.

Health Care Costs Attributable to Prostate Cancer in British Columbia, Canada: A Population-Based Cohort Study

We aimed to estimate the total health care costs attributable to prostate cancer (PCa) during care phases by age, cancer stage, tumor grade, and primary treatment in the first year in British Columbia (BC), Canada. Using linked administrative health data, we followed a cohort of men aged ≥ 50 years at diagnosis with PCa between 2010 and 2017 (Cohort 1) from the diagnosis date until the date of death, the last date of observation, or 31 December 2019. Patients who died from PCa after 1 January 2010, were selected for Cohort 2. PCa attributable costs were estimated by comparing costs in patients to matched controls. Cohort 1 (n = 22,672) had a mean age of 69.9 years (SD = 8.9) and a median follow-up time of 5.2 years. Cohort 2 included 6942 patients. Mean PCa attributable costs were the highest during the first year after diagnosis ($14,307.9 [95% CI: $13,970.0, $14,645.8]) and the year before death ($9959.7 [$8738.8, $11,181.0]). Primary treatment with radiation therapy had significantly higher costs each year after diagnosis than a radical prostatectomy or other surgeries in advanced-stage PCa. Androgen deprivation therapy (and/or chemotherapy) had the highest cost for high-grade and early-stage cancer during the three years after diagnosis. No treatment group had the lowest cost. Updated cost estimates could inform economic evaluations and decision-making.

A Novel Blood Proteomic Signature for Prostate Cancer

Prostate cancer is the most common malignant tumour in men. Improved testing for diagnosis, risk prediction, and response to treatment would improve care. Here, we identified a proteomic signature of prostate cancer in peripheral blood using data-independent acquisition mass spectrometry combined with machine learning. A highly predictive signature was derived, which was associated with relevant pathways, including the coagulation, complement, and clotting cascades, as well as plasma lipoprotein particle remodeling. We further validated the identified biomarkers against a second cohort, identifying a panel of five key markers (GP5, SERPINA5, ECM1, IGHG1, and THBS1) which retained most of the diagnostic power of the overall dataset, achieving an AUC of 0.91. Taken together, this study provides a proteomic signature complementary to PSA for the diagnosis of patients with localised prostate cancer, with the further potential for assessing risk of future development of prostate cancer. Data are available via ProteomeXchange with identifier PXD025484.

Increasing the value of PSA through improved implementation

Low-value testing and treatment contribute to billions of dollars in waste to the United States health care system annually. High frequency, low-cost testing, including prostate-specific antigen (PSA) testing, is a major contributor to this inefficient health care delivery. Despite decreasing mortality of prostate cancer over the last few decades, the reputation of prostate specific antigen (PSA) for prostate cancer screening has fluctuated over the last decade due to lack of clarity of the benefits of screening and high risk for overtreatment. The value of PSA could be improved by efficient implementation of smarter testing strategies that reduce the harms and increase the benefits.

Prostate cancer extracellular vesicle digital scoring assay - a rapid noninvasive approach for quantification of disease-relevant mRNAs

Optimizing outcomes in prostate cancer (PCa) requires precision in characterization of disease status. This effort was directed at developing a PCa extracellular vesicle (EV) Digital Scoring Assay (DSA) for detecting metastasis and monitoring progression of PCa. PCa EV DSA is comprised of an EV purification device (i.e., EV Click Chip) and reverse-transcription droplet digital PCR that quantifies 11 PCa-relevant mRNA in purified PCa-derived EVs. A Met score was computed for each plasma sample based on the expression of the 11-gene panel using the weighted Z score method. Under optimized conditions, the EV Click Chips outperformed the ultracentrifugation or precipitation method of purifying PCa-derived EVs from artificial plasma samples. Using PCa EV DSA, the Met score distinguished metastatic (n = 20) from localized PCa (n = 20) with an area under the receiver operating characteristic curve of 0.88 (95% CI:0.78-0.98). Furthermore, longitudinal analysis of three PCa patients showed the dynamics of the Met scores reflected clinical behavior even when disease was undetectable by imaging. Overall, a sensitive PCa EV DSA was developed to identify metastatic PCa and reveal dynamic disease states noninvasively. This assay may complement current imaging tools and blood-based tests for timely detection of metastatic progression that can improve care for PCa patients.

Imaging of prostate cancer: optimizing affinity to prostate specific membrane antigen by spacer modifications in a tumor spheroid model

Early diagnosis of prostate cancer (PCa) is crucial for staging, treatment and management of patients. Prostate specific membrane antigen (PSMA), highly over-expressed on PCa cells, is an excellent target for selective imaging of PCa. In recent years, various scaffolds have been explored as potential carriers to target diagnostic and therapeutic agents to PSMA⁺ tumour cells. Numerous fluorescent or radioisotope probes linked via a peptide linker have been developed that selectively binds to PCa cells. However, there are very few reports that examine the effects of chemical modifications in the peptide linker of an imaging probe on its affinity to PSMA protein. This report systematically investigates the impact of hydrophobic aromatic moieties in the peptide linker on PSMA affinity and in vitro performance. For this, a series of fluorescent bioconjugates 12-17 with different aromatic spacers were designed, synthesized, and their interactions within the PSMA pocket were first analysed in silico. Cell uptake studies were then performed for 12-17 in PSMA⁺ cell lines and 3D tumour models in vitro. Binding affinity values of 12-17 were found to be in the range of 36 to 157.9 nM, and 12 with three aromatic groups in the spacer exhibit highest affinity (K_D = 36 nM) compared to 17 which is devoid of aromatic groups. These studies suggest that aromatic groups in the spacer region can significantly affect deep tissue imaging of fluorescent bioconjugates. Bioconjugate 12 can be a promising diagnostic tool, and conjugation to near-infrared agents would further its applications in deep-tissue imaging and surgery. Communicated by Ramaswamy H. Sarma.

The Influence of Practice Structure on Urologists' Treatment of Men With Low-Risk Prostate Cancer

BACKGROUND

Vertical and horizontal integration among health care providers has transformed the practice arrangements under which many physicians work.

OBJECTIVE

To examine the influence of type of practice structure, and by implication the financial incentives associated with each structure, on treatment received among men newly diagnosed with low-risk prostate cancer.

RESEARCH DESIGN

We compiled a unique database from cancer registry records from 4 large states, Medicare enrollment and claims for the years 2005-2014 and SK & A physician surveys corroborated by extensive internet searches. We estimated a multinomial logit model to examine the influence of urologist practice structure on type of initial treatment received.

RESULTS

The probability of being monitored with active surveillance was 7.4% and 4.2% points higher for men treated by health system and nonhealth system employed urologists ( P <0.01), respectively, in comparison to men treated by single specialty urology practices. Among multispecialty practices, the rate of active surveillance use was 3% points higher compared with single specialty urology practices( P <0.01). Use of intensity modulated radiation therapy among urologists with ownership in intensity modulated radiation therapy was 17.4% points higher compared with urologists working in small single specialty practices.

CONCLUSIONS

Physician practice structure attributes are significantly associated with type of treatment received but few studies control for such factors. Our findings-coupled with the observation that urologist practice structure shifted substantially over this time period due to mergers of small urology groups-provide one explanation for the limited uptake of active surveillance among men with low-risk disease in the US.

The Economic Burden of Localized Prostate Cancer and Insights Derived from Cost-Effectiveness Studies of the Different Treatments

Prostate cancer has huge health and societal impacts, and there is no clear consensus on the most effective and efficient treatment strategy for this disease, particularly for localized prostate cancer. We have reviewed the scientific literature describing the economic burden and cost-effectiveness of different treatment strategies for localized prostate cancer in OECD countries. We initially identified 315 articles, studying 13 of them in depth (those that met the inclusion criteria), comparing the social perspectives of cost, time period, geographical area, and severity. The economic burden arising from prostate cancer due to losses in productivity and increased caregiver load is noticeable, but clinical decision-making is carried out with more subjective variability than would be advisable. The direct cost of the intervention was the main driver for the treatment of less severe cases of prostate cancer, whereas for more severe cases, the most important determinant was the loss in productivity. Newer, more affordable radiotherapy strategies may play a crucial role in the future treatment of early prostate cancer. The interpretation of our results depends on conducting thorough sensitivity analyses. This approach may help better understand parameter uncertainty and the methodological choices discussed in health economics studies. Future results of ongoing clinical trials that are considering genetic characteristics in assessing treatment response of patients with localized prostate cancer may shed new light on important clinical and pharmacoeconomic decisions.

Alcohol Abuse, Morbid Obesity, Depression, Congestive Heart Failure, and Chronic Pulmonary Disease are Risk Factors for 90-Day Readmission After Arthroscopic Rotator Cuff Repair

Purpose

The purpose of this study was to report the rate and causes of 90-day readmissions after arthroscopic rotator cuff repair.

Methods

A retrospective query from January 2005 to March 2014 was performed using a nationwide administrative claims registry. Patients and complications were identified using International Classification of Disease, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes. Patients who underwent arthroscopic rotator cuff repair (RCR) and were readmitted within 90 days after their index procedure were identified. Patients not readmitted represented controls. Patients readmitted were stratified into separate cohorts depending on the primary cause of readmission, which included cardiac, endocrine, hematological, infectious, gastrointestinal, musculoskeletal (MSK), neoplastic, neurological or psychiatric, pulmonary, and renal. Risk factors assessed were comorbidities comprising the Elixhauser-Comorbidity Index (ECI). Primary outcomes analyzed and compared included cause for readmission, patient demographics, risk factors, in-hospital length of stay (LOS), and costs. Pearson’s chi-square was used to compare patient demographics, and multivariate binomial logistic regression was used to calculate odds ratios (OR) on patient-related risk factors for 90-day readmissions.

Results

10,425 readmitted patients and 301,625 control patients were identified, representing a 90-day readmission rate of 3.5%. The causes of readmissions were primarily related to infectious diseases (15%), MSK (15%), and cardiac (14%) complications. The most common MSK readmissions were osteoarthrosis of the leg or shoulder (24.8%) and spinal spondylosis (8.4%). Multivariate binomial logistic regression analyses demonstrated patients with alcohol abuse (OR, 1.42; P < .0001), morbid obesity (OR, 1.38; P < .0001), depression (OR, 1.35; P < .0001), congestive heart failure (OR, 1.34; P < 0.0001), and chronic pulmonary disease (OR, 1.28; P < .0001) were at the greatest risk of readmissions after RCR.

Conclusions

Significant differences exist among patients readmitted, and those patients who do not require hospital readmission within 90 days following arthroscopic rotator cuff repairs. Readmissions are associated with significant patient comorbidities and were primarily related to medically based complications.

Level of Evidence

Level III, prognostic, retrospective cohort study.

Metronomic Chemotherapy for Advanced Prostate Cancer: A Literature Review

Metastatic castration-resistant prostate cancer (mCRPC) is the ultimately lethal form of prostate cancer. Docetaxel chemotherapy was the first life-prolonging treatment for mCRPC; however, the standard maximally tolerated dose (MTD) docetaxel regimen is often not considered for patients with mCRPC who are older and/or frail due to its toxicity. Low-dose metronomic chemotherapy (LDMC) is the frequent administration of typically oral and off-patent chemotherapeutics at low doses, which is associated with a superior safety profile and higher tolerability than MTD chemotherapy. We conducted a systematic literature review using the PUBMED, EMBASE, and MEDLINE electronic databases to identify clinical studies that examined the impact of LDMC on patients with advanced prostate cancer. The search identified 30 reports that retrospectively or prospectively investigated LDMC, 29 of which focused on mCRPC. Cyclophosphamide was the most commonly used agent integrated into 27/30 (90%) of LDMC regimens. LDMC resulted in a clinical benefit rate of 56.8 ± 24.5% across all studies. Overall, there were only a few non-hematological grade 3 or 4 adverse events reported. As such, LDMC is a well-tolerated treatment option for patients with mCRPC, including those who are older and frail. Furthermore, LDMC is considered more affordable than conventional mCRPC therapies. However, prospective phase III trials are needed to further characterize the efficacy and safety of LDMC in mCRPC before its use in practice.

Red Blood Cell Distribution Width Is Associated with All-cause Mortality but Not Adverse Cancer-specific Outcomes in Men with Clinically Localized Prostate Cancer Treated with Radical Prostatectomy: Findings Based on a Multicenter Shared Equal Access Regional Cancer Hospital Registry

BACKGROUND

Recent reports with a small number of patients showed an association of red blood cell distribution width (RDW) with prostate cancer (PCa) progression.

OBJECTIVE

To investigate whether preoperative RDW can serve as a prognostic marker in patients with PCa undergoing radical prostatectomy (RP) in a large, equal access, and diverse patient cohort.

DESIGN SETTING AND PARTICIPANTS

Data were retrospectively collected on 4756 men treated with RP at eight Veteran Affairs medical centers within the Shared Equal Access Regional Cancer Hospital (SEARCH) database from 1999 through 2017.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Biochemical recurrence (BCR) was the primary outcome, while metastasis, all-cause mortality (ACM), and prostate cancer-specific mortality (PCSM) were secondary outcomes.

RESULTS AND LIMITATIONS

The mean (standard deviation) age was 62 yr (6.1), and 1589 (33%) men were black. The median (interquartile range) follow-up was 82 mo (46-127). Preoperative RDW either as a continuous variable or when stratified by quartiles was not associated with BCR. Likewise, preoperative RDW was not associated with metastases or PCSM. However, higher RDW was significantly associated with higher ACM, both as a continuous variable (p < 0.001) and when stratified by quartiles in univariable and multivariable models (p < 0.001). RDW was found to be correlated with D'Amico risk classification of PCa. Study limitations include its retrospective nature and lack of data regarding advanced PCa.

CONCLUSIONS

Preoperative RDW was not associated with PCa outcomes in men treated with RP but was associated with ACM. While RDW may be a biomarker of overall health, it is not a biomarker for PCa outcomes. These results emphasize the importance of diverse, larger sized studies in genitourinary cancer research.

PATIENT SUMMARY

Prostate cancer includes a wide spectrum of diseases with different genetic, pathological, and oncological behaviors. Red blood cell distribution width is helpful in predicting the overall survival for a localized prostate cancer patient, and hence, it can help inform personalized treatment decisions and operative care.

Germline variants disrupting microRNAs predict long-term genitourinary toxicity after prostate cancer radiation

BACKGROUND AND PURPOSE

The purpose of this study was to determine whether single nucleotide polymorphisms disrupting microRNA targets (mirSNPs) can serve as predictive biomarkers for toxicity after radiotherapy for prostate cancer and whether these may be differentially predictive depending on radiation fractionation.

MATERIALS AND METHODS

We identified 201 men treated with two forms of definitive radiotherapy for prostate cancer at two institutions: 108 men received conventionally-fractionated radiotherapy (CF-RT) and 93 received stereotactic body radiotherapy (SBRT). Germline DNA was evaluated for the presence of functional mirSNPs. Random forest, boosted trees and elastic net models were developed to predict late grade ≥2 GU toxicity by the RTOG scale.

RESULTS

The crude incidence of late grade ≥2 GU toxicity was 16% after CF-RT and 15% after SBRT. An elastic net model based on 22 mirSNPs differentiated CF-RT patients at high risk (71.5%) versus low risk (7.5%) for toxicity, with an area under the curve (AUC) values of 0.76-0.81. An elastic net model based on 32 mirSNPs differentiated SBRT patients at high risk (64.7%) versus low risk (3.9%) for toxicity, with an area under the curve (AUC) values of 0.81-0.87. These models were specific to treatment type delivered. Prospective studies are warranted to further validate these results.

CONCLUSION

Predictive models using germline mirSNPs have high accuracy for predicting late grade ≥2 GU toxicity after either CF-RT or SBRT, and are unique for each treatment, suggesting that germline predictors of late radiation sensitivity are fractionation-dependent. Prospective studies are warranted to further validate these results.

Patient Decision-Making Factors in Aggressive Treatment of Low-Risk Prostate Cancer

Background

Active surveillance (AS) is underutilized for low-risk prostate cancer. This study examines decision-making factors associated with AS vs aggressive treatment in a population-based cohort of low-risk patients.

Methods

Newly diagnosed patients (n = 599) were enrolled through the North Carolina Central Cancer Registry from 2011 to 2013 and surveyed regarding 5 factors that may impact treatment decision making: perceived cancer aggressiveness, aggressiveness of treatment intent, most important goal (eg, cure, quality of life), primary information source, and primary decision maker. We examined the association between treatment decision-making factors with patient choice for AS vs aggressive treatment using multivariable logistic regression analysis.

Results

This is a sociodemographically diverse cohort reflective of the population-based design, with 37.6% overall (47.6% among very low-risk patients) choosing AS. Aggressive treatment intent (odds ratio [OR] = 7.09, 95% confidence interval [CI] = 4.57 to 11.01), perceived cancer aggressiveness (OR = 4.93, 95% CI = 2.71 to 8.97), most important goal (cure vs other, OR = 1.72, 95% CI = 1.12 to 2.63), and primary information source (personal and family vs physician, OR = 1.76, 95% CI = 1.10 to 2.82) were associated with aggressive treatment. Overall, 88.4% of patients (92.2% among very low-risk) who indicated an intent to treat the cancer “not very aggressively” chose AS.

Conclusions

These data from the patient’s perspective shed new light on potentially modifiable factors that can help further increase AS uptake among low-risk patients. Helping more low-risk patients feel comfortable with a “not very aggressive” treatment approach may be especially important, which can be facilitated through patient education interventions to improve the understanding of the cancer diagnosis and AS having a curative intent.

Prostate Cancer Support Groups: The Unadvertised Camaraderie

Prostate cancer (PCa), in particular, is known to cause significant psychosocial distress during the duration of a patient’s treatment due to its uncertainty and demasculinizing side effects. Prostate cancer support groups (PCSGs) have been proven to be beneficial, yet are underutilized by the majority of PCa patients and physicians. A thorough review of the literature was performed for articles pertaining to prostate cancer support groups. We sought to identify factors contributing to the psychological burden of the disease, factors that influenced patients to join, and barriers to participation in a PCSG. Additionally, the characteristics and format of PCSGs, as well as outcomes (i.e. quality of life), were evaluated.

Trends and variations in utilization and costs of radiotherapy for prostate cancer: A SEER medicare analysis from 2007 through 2016

OBJECTIVE

To assess recent changes and disparities in utilization and costs of radiotherapy in Medicare beneficiaries with prostate cancer.

METHODS

Surveillance, Epidemiology and End Results (SEER) -Medicare linked data from 2006-2016 were used to identify continuously enrolled Medicare beneficiaries with a first-time diagnosis of prostate cancer who, within 12 months of diagnosis, underwent at least one radiotherapy related service. Trends in the utilization of different radiotherapy techniques over time, yearly changes in per-patient costs of radiotherapy, and effect of socio-demographic and clinical characteristics on total cost were measured. Per patient annual costs, annual incidence of prostate cancer, and utilization of radiotherapy were used to estimate total costs of radiotherapy to the Medicare program.

RESULTS

For Medicare beneficiaries with a first-time diagnosis of prostate cancer, the utilization of intensity modulated radiation therapy (IMRT), proton therapy, and stereotactic body radiation therapy (SBRT) increased 23.62%, 0.74% and 1.61% respectively (p <0.0001) while brachytherapy decreased 17.04% (p <0.0001). Cost per beneficiary decreased $340.24 (95% CI: $136.05 - $544.43) annually (p = 0.0065). Age, registry region, and Gleason score were all associated with expenditures. The total cost to the Medicare program was estimated at US $1.16 billion in the year 2016.

DISCUSSION

In Medicare beneficiaries with prostate cancer treated with radiotherapy, IMRT is the primary mode of treatment. Utilization of brachytherapy decreased significantly despite the efficacy and cost-effectiveness. Although per patient costs have decreased, the share of patient responsibility remained unaltered across years. The current costs to Medicare of radiotherapy for newly diagnosed prostate cancer patients is substantial.

Efficacy and Safety of Cabazitaxel Versus Abiraterone or Enzalutamide in Older Patients with Metastatic Castration-resistant Prostate Cancer in the CARD Study

BACKGROUND

In the CARD study (NCT02485691), cabazitaxel significantly improved median radiographic progression-free survival (rPFS) and overall survival (OS) versus abiraterone/enzalutamide in patients with metastatic castration-resistant prostate cancer (mCRPC) who had previously received docetaxel and progressed ≤12 mo on the alternative agent (abiraterone/enzalutamide).

OBJECTIVE

To assess cabazitaxel versus abiraterone/enzalutamide in older (≥70 yr) and younger (<70 yr) patients in CARD.

DESIGN, SETTING, AND PARTICIPANTS

Patients with mCRPC were randomized 1:1 to cabazitaxel (25 mg/m² plus prednisone and granulocyte colony-stimulating factor) versus abiraterone (1000 mg plus prednisone) or enzalutamide (160 mg).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Analyses of rPFS (primary endpoint) and safety by age were prespecified; others were post hoc. Treatment groups were compared using stratified log-rank or Cochran-Mantel-Haenszel tests.

RESULTS AND LIMITATIONS

Of the 255 patients randomized, 135 were aged ≥70 yr (median 76 yr). Cabazitaxel, compared with abiraterone/enzalutamide, significantly improved median rPFS in older (8.2 vs 4.5 mo; hazard ratio [HR] = 0.58; 95% confidence interval [CI] = 0.38-0.89; p = 0.012) and younger (7.4 vs 3.2 mo; HR = 0.47; 95% CI = 0.30-0.74; p < 0.001) patients. The median OS of cabazitaxel versus abiraterone/enzalutamide was 13.9 versus 9.4 mo in older patients (HR = 0.66; 95% CI = 0.41-1.06; p = 0.084), and it was 13.6 versus 11.8 mo in younger patients (HR = 0.66; 95% CI = 0.41-1.08; p = 0.093). Progression-free survival, prostate-specific antigen, and tumor and pain responses favored cabazitaxel, regardless of age. Grade ≥3 treatment-emergent adverse events (TEAEs) occurred in 58% versus 49% of older patients receiving cabazitaxel versus abiraterone/enzalutamide and 48% versus 42% of younger patients. In older patients, cardiac adverse events were more frequent with abiraterone/enzalutamide; asthenia and diarrhea were more frequent with cabazitaxel.

CONCLUSIONS

Cabazitaxel improved efficacy outcomes versus abiraterone/enzalutamide in patients with mCRPC after prior docetaxel and abiraterone/enzalutamide, regardless of age. TEAEs were more frequent among older patients. The cabazitaxel safety profile was manageable across age groups.

PATIENT SUMMARY

Clinical trial data showed that cabazitaxel improved survival versus abiraterone/enzalutamide with manageable side effects in patients with metastatic castration-resistant prostate cancer who had previously received docetaxel and the alternative agent (abiraterone/enzalutamide), irrespective of age.

Association between Site-of-Care and the Cost and Modality of Radiotherapy for Prostate Cancer: Analysis of Medicare Beneficiaries from 2015 to 2017

Among 84,447 radiotherapy (RT) courses for Medicare beneficiaries age ≥ 65 with prostate cancer treated with external beam RT (EBRT), brachytherapy, or both, 42,608 (51%) were delivered in hospital-affiliated and 41,695 (49%) in freestanding facilities. Freestanding centers were less likely to use EBRT + brachytherapy than EBRT (OR 0.84 [95%CI 0.84-0.84]; p < .001). Treatment was more costly in freestanding centers (mean difference $2,597 [95%CI $2,475-2,719]; p < .001). Adjusting for modality and fractionation, RT in hospital-affiliated centers was more costly (mean difference $773 [95%CI $693-853]; p < .001). Freestanding centers utilized more expensive RT delivery, but factors unrelated to RT modality or fractionation rendered RT more costly at hospital-affiliated centers.

Should Grade Group 1 (GG1) be called cancer?

INTRODUCTION

ISUP Grade Group 1 prostate cancer is the lowest histologic grade of prostate cancer with a clinically indolent course. Removal of the term 'cancer' has been proposed and has historical precedent both in urothelial and thyroid carcinoma.

METHODS

Evidence-based review identifying arguments for and against Grade Group 1 being referred to as cancer.

RESULTS

Grade Group 1 has histologic evidence of tissue microinvasion and 0.3-3% rate of extraprostatic extension. Genomic evaluation suggests overlap of a minority of Grade Group 1 cancers with those of Grade Group 2. Conversely, Grade Group 1 tumors appear to have distinct genetic and genomic profiles from Grade Group 3 or higher tumors. Grade Group 1 has no documented ability for regional or distant metastasis and long-term follow up after treatment or active surveillance is safe with excellent oncologic outcomes.

DISCUSSION

Grade Group 1 prostate cancer, while showing evidence of neoplasia on histology has a remarkably indolent natural history more akin to non-neoplastic precursor lesions. Consideration should be given to renaming Grade Group 1 prostate cancer, which has the potential to minimize overtreatment, treatment-related side effects, patient anxiety, and financial burden on the healthcare system.

Real-world Evidence to Estimate Prostate Cancer Costs for First-line Treatment or Active Surveillance

Background

Prostate cancer is the most common cancer in men and second leading cause of cancer-related deaths. Changes in screening guidelines, adoption of active surveillance (AS), and implementation of high-cost technologies have changed treatment costs. Traditional cost-effectiveness studies rely on clinical trial protocols unlikely to capture actual practice behavior, and existing studies use data predating new technologies. Real-world evidence reflecting these changes is lacking.

Objective

To assess real-world costs of first-line prostate cancer management.

Design setting and participants

We used clinical electronic health records for 2008-2018 linked with the California Cancer Registry and the Medicare Fee Schedule to assess costs over 24 or 60 mo following diagnosis. We identified surgery or radiation treatments with structured methods, while we used both structured data and natural language processing to identify AS.

Outcome measurements and statistical analysis

Our results are risk-stratified calculated cost per day (CCPD) for first-line management, which are independent of treatment duration. We used the Kruskal-Wallis test to compare unadjusted CCPD while analysis of covariance log-linear models adjusted estimates for age and Charlson comorbidity.

Results and limitations

In 3433 patients, surgery (54.6%) was more common than radiation (22.3%) or AS (23.0%). Two years following diagnosis, AS ($2.97/d) was cheaper than surgery ($5.67/d) or radiation ($9.34/d) in favorable disease, while surgery ($7.17/d) was cheaper than radiation ($16.34/d) for unfavorable disease. At 5 yr, AS ($2.71/d) remained slightly cheaper than surgery ($2.87/d) and radiation ($4.36/d) in favorable disease, while for unfavorable disease surgery ($4.15/d) remained cheaper than radiation ($10.32/d). Study limitations include information derived from a single healthcare system and costs based on benchmark Medicare estimates rather than actual payment exchanges.

Patient summary

Active surveillance was cheaper than surgery (-47.6%) and radiation (-68.2%) at 2 yr for favorable-risk disease, which decreased by 5 yr (-5.6% and -37.8%, respectively). Surgery was less costly than radiation for unfavorable risk for both intervals (-56.1% and -59.8%, respectively).

Health care spending in prostate cancer: An assessment of characteristics and health care utilization of high resource-patients

BACKGROUND

Prostate cancer ranks among the top 5 cancers in contribution to national expenditures. Previous reports have identified that 5% of the population accounts for 50% of the nation's annual health care spending. To date, the assessment of the top 5% resource-patients among men diagnosed with prostate cancer (PCa) has never been performed. We investigate the determinants and health care utilization of high resource-patients diagnosed with PCa using a population-based cohort using the Surveillance, Epidemiology, and End Results Medicare-linked database.

METHODS

Men aged ≥66-year-old with a primary diagnosis of PCa in 2009 were identified. High resource spenders were defined as the top 5% of the sum of the total cost incurred for all services rendered per beneficiary. The spending in each group and predictors of being a high resource-patient were assessed.

RESULTS

The top 5% resource-patients consisted of 646 men who spent a total of $62,474,504, comprising 26% of the total cost incurred for all 12,875 men who were diagnosed with PCa in 2009. Of the top 5% resource-patients, the average amount spent per patient was $96,710 vs. $14,664 among the bottom 95% resource-patients. In adjusted analyses, older (odds ratio [OR]: 1.02, 95% confidence interval [CI]: 1.00-1.03), Charlson Comorbidity Index ≥2 (OR: 3.78, 95% CI: 3.10-4.60) men, and advanced disease (metastasis OR: 2.29, 95% CI: 1.68-3.11) were predictors of being a top 5% resource-patient. Of these patients, 210 men died within 1 year of PCa diagnosis (32.5%) vs. 606 men of the bottom 95% resource-patients (5.0%, P < 0.001).

CONCLUSION

Five percent of men diagnosed with PCa bore 26% of the total cost incurred for all men diagnosed with the disease in 2009. Multimorbidity and advanced disease stage represent the primary drivers of being a high-resource PCa patient. Multidisciplinary care and shared decision-making is encouraged for such patients to better manage cost and quality of care.

Prognostic capabilities and clinical utility of cell cycle progression testing, prostate imaging reporting and data system, version 2, and clinicopathologic data in management of localized prostate cancer

OBJECTIVES

To compare the prognostic capabilities and clinical utility of the cell cycle progression (CCP) gene expression classifier test, multiparametric magnetic resonance imaging (mpMRI) with Prostate Imaging Reporting and Data System (PI-RADS) scoring, and clinicopathologic data in select prostate cancer (PCa) medical management scenarios.

PATIENTS AND METHODS

Retrospective, observational analysis of patients (N = 222) ascertained sequentially from a single urology practice from January 2015 to June 2018. Men were included if they had localized PCa, a CCP score, and an mpMRI PI-RADS v2 score. Cohort 1 (n = 156): men with newly diagnosed PCa, with or without a previous negative biopsy. Cohort 2 (n = 66): men who initiated active surveillance (AS) without CCP testing, but who received the test during AS. CCP was combined with the UCSF Cancer of the Prostate Risk Assessment (CAPRA) score to produce a clinical cell-cycle risk (CCR) score, which was reported in the context of a validated AS threshold. Spearman's rank correlation test was used to evaluate correlations between variables. Generalized linear models were used to predict binary Gleason score category and medical management selection (AS or curative therapy). Likelihood-ratio tests were used to determine predictor significance in both univariable and multivariable models.

RESULTS

In the combined cohorts, modest but significant correlations were observed between PI-RADS score and CCP (r_s = 0.22, P = 8.1 × 10^-4), CAPRA (r_s= 0.36, P = 4.8 × 10^-8), or CCR (r_s = 0.37, P = 2.0 × 10^-8), suggesting that much of the prognostic information captured by these measures is independent. When accounting for CAPRA and PI-RADS score, CCP was a significant predictor of higher-grade tumor after radical prostatectomy, with the resected tumor approximately 4 times more likely to harbor Gleason ≥4+3 per 1-unit increase in CCP in Cohort 1 (Odds Ratio [OR], 4.10 [95% confidence interval [CI], 1.46, 14.12], P = 0.006) and in the combined cohorts (OR, 3.72 [95% CI, 1.39, 11.88], P = 0.008). On multivariable analysis, PI-RADS score was not a significant predictor of post-radical prostatectomy Gleason score. Both CCP and CCR were significant and independent predictors of AS versus curative therapy in Cohort 1 on multivariable analysis, with each 1-unit increase in score corresponding to an approximately 2-fold greater likelihood of selecting curative therapy (CCP OR, 2.08 [95% CI, 1.16, 3.94], P = 0.014) (CCR OR, 2.33 [95% CI, 1.48, 3.87], P = 1.5 × 10^-4). CCR at or below the AS threshold significantly reduced the probability of selecting curative therapy over AS (OR, 0.28 [95% CI, 0.13, 0.57], P = 4.4 × 10^-4), further validating the clinical utility of the AS threshold.

CONCLUSION

CCP was a better predictor of both tumor grade and subsequent patient management than was PI-RADS. Even in the context of targeted biopsy, molecular information remains essential to ensure precise risk assessment for men with newly diagnosed PCa.

A review of current advancements and limitations of artificial intelligence in genitourinary cancers

Advances in deep learning and neural networking have allowed clinicians to understand the impact that artificial intelligence (AI) could have on improving clinical outcomes and resources expenditures. In the realm of genitourinary (GU) cancers, AI has had particular success in improving the diagnosis and treatment of prostate, renal, and bladder cancers. Numerous studies have developed methods to utilize neural networks to automate prognosis prediction, treatment plan optimization, and patient education. Furthermore, many groups have explored other techniques, including digital pathology and expert 3D modeling systems. Compared to established methods, nearly all the studies showed some level of improvement and there is evidence that AI pipelines can reduce the subjectivity in the diagnosis and management of GU malignancies. However, despite the many potential benefits of utilizing AI in urologic oncology, there are some notable limitations of AI when combating real-world data sets. Thus, it is vital that more prospective studies be conducted that will allow for a better understanding of the benefits of AI to both cancer patients and urologists.

[Noninvasive treatment of organ-confined prostate cancer in elderly patients-results of the HAROW study]

BACKGROUND

Noninvasive treatment options such as active surveillance (AS), watchful waiting (WW), and hormone deprivation therapy (HT) are particularly important in elderly patients with localized prostate cancer (PCa).

OBJECTIVES

We examine the use of these noninvasive treatment options in the everyday care in a cohort of patients ≥70 years old.

MATERIALS AND METHODS

In the HAROW study, the treatment of localized PCa under everyday conditions is investigated. The only inclusion criterion was newly diagnosed organ-confined PCa (≤cT2c). In AS, WW, and HT patients, we compared initial tumor and patient characteristics, follow-up examinations and changes of therapy.

RESULTS

Of 457 patients ≥70 years, 210 chose AS, 160 HT, and 87 WW. Observation times were 6.3 years (AS), 7.5 years (HT), and 7.0 years (WW). AS patients (73.2 years) were younger than WW (76.0 years) and HT patients (76.9 years) and had a higher proportion of low-risk tumors (80%) versus WW (31%) and HT (19%). A change of therapy was observed in 47.1% of AS, 17.2% of WW and 13.1% of HT patients. Metastasis occurred in 1.0% of AS, 4.6% of WW, and 6.9% of HT patients. Overall survival was 94.3% for AS, 90.8% for WW and 81.9% for HT. Within the first 28.4 months, the mean number of PSA determinations did not differ between AS and WW (6.1 vs. 5.2; p = 0.09); a rebiopsy was performed in 37.6% of AS, 11.4% of WW, and 17% of HT patients.

CONCLUSIONS

The allocation to curative and palliative strategies should be made according to patient and tumor characteristics by definition. Palliative procedures may represent concepts in older patients who initially chose a curative AS strategy.

Economic Outcomes in Patients with Chemotherapy-Naïve Metastatic Castration-Resistant Prostate Cancer Treated with Enzalutamide or Abiraterone Acetate Plus Prednisone

Introduction

Prostate cancer (PC) is the second leading cause of cancer death among US men and accounts for considerable healthcare expenditures. We evaluated economic outcomes in men with chemotherapy-naïve metastatic castration-resistant PC (mCRPC) treated with enzalutamide or abiraterone acetate plus prednisone (abiraterone).

Methods

We performed a retrospective analysis on 3174 men (18 years or older) utilizing the Veterans Health Administration (VHA) database from 1 April 2014 to 31 March 2018. Men with mCRPC were included if they had at least one pharmacy claim for enzalutamide or abiraterone (first claim date = index date) following surgical or medical castration, had no chemotherapy treatment within 12 months prior to the index date, and had continuous VHA enrollment for at least 12 months pre- and post-index date. Men were followed until death, disenrollment, or end of study and were 1:1 propensity score matched (PSM). All-cause and PC-related resource use and costs per patient per month (PPPM) in the 12 months post index were compared between matched cohorts.

Results

We identified 1229 men with mCRPC prescribed enzalutamide and 1945 prescribed abiraterone with mean ages of 74 and 73 years, respectively. After PSM, each cohort had 1160 patients. The enzalutamide cohort had fewer all-cause (2.51 vs 2.86; p < 0.0001) and PC-related outpatient visits (0.86 vs 1.03; p < 0.0001), with corresponding lower all-cause ($2588 vs $3115; p < 0.0001) and PC-related ($1356 vs $1775; p < 0.0001) PPPM outpatient costs compared with the abiraterone cohort. All-cause total costs (medical and pharmacy) PPPM ($8085 vs $9092; p = 0.0002) and PC-related total costs PPPM ($6321 vs $7280; p < 0.0001) were significantly lower in the enzalutamide cohort compared with the abiraterone cohort.

Conclusions

Enzalutamide-treated men with chemotherapy-naïve mCRPC had significantly lower resource utilization and healthcare costs compared with abiraterone-treated men.

Electronic Supplementary Material

The online version of this article (10.1007/s12325-020-01260-x) contains supplementary material, which is available to authorized users.

Prostate cancer (PC) is the second leading cause of death among men with cancer in the USA. Healthcare costs associated with PC, including hospitalizations, outpatient visits, and medications prescribed to treat adverse effects, depend on the severity of the disease and intensity of treatment, but are generally very high. Enzalutamide and abiraterone acetate with prednisone (abiraterone) are both approved treatments for men with PC that does not respond to treatments that reduce the male hormone testosterone, known as castration-resistant PC (CRPC). These drugs are associated with varying treatment duration and different adverse effects, and therefore could result in differences in the use of healthcare resources and overall cost of treatment. Here we evaluated the healthcare resource utilization (HCRU), which was calculated as the average number of healthcare encounters, including inpatient stays, outpatient visits, and pharmacy visits, and length of inpatient stays, and treatment costs associated with use of enzalutamide or abiraterone by men with metastatic CRPC (mCRPC), who had not received prior chemotherapy in the Veterans Health Administration. We found that men with chemotherapy-naïve mCRPC treated with enzalutamide used less healthcare resources and incurred lower total healthcare costs than men treated with abiraterone. On average, all-cause total healthcare costs were $1007 per patient per month lower and PC-related total healthcare costs were $959 per patient per month lower for patients treated with enzalutamide than those treated with abiraterone. These results support the hypothesis that the long-term HCRU and costs of enzalutamide may be lower compared with abiraterone.

Medical innovation, education, and labor market outcomes of cancer patients

Innovations in cancer treatment have lowered mortality, but little is known about their economic benefits. We assess the effect of two decades of improvement in cancer treatment options on the labor market outcomes of breast and prostate cancer patients. In addition, we compare this effect across cancer patients with different levels of educational attainment. We estimate the effect of medical innovation on cancer patients' labor market outcomes employing tax return and cancer registry data from Canada and measuring medical innovation by using the number of approved drugs and a quality-adjusted patent index. We find that innovations in cancer treatment during the 1990s and 2000s reduced the negative employment effects of cancer by 63% to 70%, corresponding to a reduction in the economic costs of prostate and breast cancer diagnoses by 13,500 and 5800 dollars per year, respectively. The benefits of medical innovation are limited to cancer patients with postsecondary education.

Financial Toxicity and Cancer Therapy: A Primer for Radiation Oncologists

The diagnosis and treatment of cancer places patients at risk for serious financial consequences, which are detrimental to overall health and well-being. The concept of financial toxicity (FT) describes monetary and health implications related to the financial burden of receiving care. To investigate this important area, the authors first explore aspects of the modern American health care insurance system that relate to cancer care. Then they summarize relevant literature across multiple domains of FT that include monetary, functional, and patient-reported measures. The authors conclude by making simple recommendations to begin addressing FT in clinical practice.

Cartilage oligomeric matrix protein in patients with osteoarthritis is independently associated with metastatic disease in prostate cancer

Metastatic prostate cancer has a 5-year survival rate of 30%. Identifying predictors of metastasis outcome could potentially reduce patient mortality. The objective of this study was to determine whether osteoarthritis had an impact on outcomes of prostate cancer including death, local recurrence and/or metastasis and to determine whether cartilage oligomeric matrix protein was involved. We performed a retrospective case-control study of patients with prostate cancer with and without the diagnosis of osteoarthritis and completed immunohistochemistry (IHC) analysis of prostate (n=20) and lymph node (n=7) surgical specimens. We evaluated death, local recurrence and metastatic disease by various IHC biomarkers including prostate specific membrane antigen (PSMA), cartilage oligomeric matrix protein (COMP), CD31, and Ki-67. Our model identified osteoarthritis as an independent risk factor for metastatic disease (OR 5.24, 95% CI 1.49 - 18.41). Most notably, when joint arthroplasty was included in the model, osteoarthritis was no longer an independent risk factor for this outcome (p=0.071). IHC demonstrated that those with osteoarthritis, had greater expression of COMP in the prostate samples (mean 23.9% vs 5.84%, p<0.05) but not of Ki-67, CD31, or PSMA. This study identified and quantified increased metastatic disease in patients with osteoarthritis. Also, patients with osteoarthritis expressed increased COMP levels in the prostate and most likely in distant lymphatic nodes. Moreover, our findings suggest that joint arthroplasty may affect the ability of osteoarthritis to promote metastasis, which could impact treatment protocols and survival outcomes of the most common cause of cancer-related death (metastasis) in the United States.