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Naser-Tavakolian A, Gale R, Luu M, Masterson JM, Venkataramana A, Khodyakov D, Anger JT, Posadas E, Sandler H, Freedland SJ, Spiegel B, Daskivich TJ. Use of Persuasive Language in Communication of Risk during Prostate Cancer Treatment Consultations. Med Decis Making 2024; 44:320-334. [PMID: 38347686 DOI: 10.1177/0272989x241228612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Physician treatment preference may influence how risks are communicated in prostate cancer consultations. We identified persuasive language used when describing cancer prognosis, life expectancy, and side effects in relation to a physician's recommendation for aggressive (surgery/radiation) or nonaggressive (active surveillance/watchful waiting) treatment. METHODS A qualitative analysis was performed on transcribed treatment consultations of 40 men with low- and intermediate-risk prostate cancer across 10 multidisciplinary providers. Quotes pertaining to cancer prognosis, life expectancy, and side effects were randomized. Coders predicted physician treatment recommendations from isolated blinded quotes. Testing characteristics of consensus predictions against the physician's treatment recommendation were reported. Coders then identified persuasive strategies favoring aggressive/nonaggressive treatment for each quote. Frequencies of persuasive strategies favoring aggressive/nonaggressive treatment were reported. Logistic regression quantified associations between persuasive strategies and physician treatment recommendations. RESULTS A total of 496 quotes about cancer prognosis (n = 127), life expectancy (n = 51), and side effects (n = 318) were identified. The accuracy of predicting treatment recommendation based on individual quotes containing persuasive language (n = 256/496, 52%) was 91%. When favoring aggressive treatment, persuasive language downplayed side effect risks and amplified cancer risk (recurrence, progression, or mortality). Significant predictors (P < 0.05) of aggressive treatment recommendation included favorable side effect interpretation, downplaying side effects, and long time horizon for cancer risk due to longevity. When favoring nonaggressive treatment, persuasive language amplified side effect risks and downplayed cancer risk. Significant predictors of nonaggressive treatment recommendation included unfavorable side effect interpretation, favorable interpretation of cancer risk, and short time horizon for cancer risk due to longevity. CONCLUSIONS Physicians use persuasive language favoring their preferred treatment, regardless of whether their recommendation is appropriate. IMPLICATIONS Clinicians should quantify risk so patients can judge potential harm without solely relying on persuasive language. HIGHLIGHTS Physicians use persuasive language favoring their treatment recommendation when communicating risks of prostate cancer treatment, which may influence a patient's treatment choice.Coders predicted physician treatment recommendations based on isolated, randomized quotes about cancer prognosis, life expectancy, and side effects with 91% accuracy.Qualitative analysis revealed that when favoring nonaggressive treatment, physicians used persuasive language that amplified side effect risks and downplayed cancer risk. When favoring aggressive treatment, physicians did the opposite.Providers should be cognizant of using persuasive strategies and aim to provide quantified assessments of risk that are jointly interpreted with the patient so that patients can make evidence-based conclusions regarding risks without solely relying on persuasive language.
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Affiliation(s)
| | - Rebecca Gale
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael Luu
- Department of Biostatistics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John M Masterson
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | - Jennifer T Anger
- Department of Urology, University of California, San Diego, San Diego, CA, USA
| | - Edwin Posadas
- Department of Medicine, Division of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Howard Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephen J Freedland
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Section of Urology, Durham VA Medical Center, Durham, NC, USA
| | - Brennan Spiegel
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, Divisions of Gastroenterology and Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Timothy J Daskivich
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Daskivich TJ, Naser-Tavakolian A, Gale R, Luu M, Friedrich N, Venkataramana A, Khodyakov D, Posadas E, Sandler H, Spiegel B, Freedland SJ. Variation in communication of side effects in prostate cancer treatment consultations. Prostate Cancer Prostatic Dis 2024:10.1038/s41391-024-00806-2. [PMID: 38396054 DOI: 10.1038/s41391-024-00806-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 01/29/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Effective communication of treatment side effects (SE) is critical for shared decision-making (SDM) in localized prostate cancer. We sought to qualitatively characterize how physicians communicate SE in consultations. METHODS We transcribed 50 initial prostate cancer treatment consultations across nine multidisciplinary providers (Urologists, Radiation Oncologists, Medical Oncologists) at our tertiary referral, academic center. Coders identified quotes describing SE and used an inductive approach to establish a hierarchy for granularity of communication: (1) not mentioned, (2) name only, (3) generalization("high"), (4) average incidence without timepoint, (5) average incidence with timepoint, and (6) precision estimate. We reported the most granular mode of communication for each SE throughout the consultation overall and across specialty and tumor risk. RESULTS Among consultations discussing surgery (n = 40), erectile dysfunction (ED) and urinary incontinence (UI) were omitted in 15% and 12%, not quantified (name only or generalization) in 47% and 30%, and noted as average incidence without timeline in 8% and 8%, respectively. In only 30% and 49% were ED and UI quantified with timeline (average incidence with timeline or precision estimate), respectively. Among consultations discussing radiation (n = 36), irritative urinary symptoms, ED, and other post-radiotherapy SE were omitted in 22%, 42%, and 64-67%, not quantified in 61%, 33%, and 23-28%, and noted as average incidence without timeline in 8%, 22%, and 6-8%, respectively. In only 3-8% were post-radiotherapy SE quantified with timeline. Specialty concordance (but not tumor risk) was associated with higher granularity of communication, though physicians frequently failed to quantify specialty-concordant SE. CONCLUSIONS SE was often omitted, not quantified, and/or lacked a timeline in treatment consultations in our sample. Physicians should articulate, quantify, and assign a timeline for SE to optimize SDM.
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Affiliation(s)
- Timothy J Daskivich
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | | | - Rebecca Gale
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael Luu
- Department of Biostatistics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nadine Friedrich
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Abhi Venkataramana
- Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | | | - Edwin Posadas
- Department of Medicine, Division of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Howard Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Brennan Spiegel
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, Divisions of Gastroenterology and Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephen J Freedland
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Section of Urology, Durham VA Medical Center, Durham, NC, USA
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Masterson JM, Zaliznyak M, Castaneda PR, Naser-Tavakolian A, Freedman AL. Residency graduates should not be expected to perform hypospadias repair without fellowship training: Results from a survey of SPU membership. J Pediatr Urol 2023; 19:538.e1-538.e5. [PMID: 36934034 DOI: 10.1016/j.jpurol.2023.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/15/2023] [Accepted: 02/22/2023] [Indexed: 03/20/2023]
Abstract
BACKGROUND Trainee autonomy has eroded over time as surgery has become more subspecialized and as attending oversight has increased, causing many trainees to seek additional fellowship training beyond residency. Less clear is whether there are cases that attendings view as "fellowship-level" or "privileged" cases in which resident-level trainees should not have high levels of autonomy due to complexity or high-stakes outcomes. OBJECTIVE We sought to better understand current attitudes and practices with regards to trainee autonomy in hypospadias repair as it represents a high complexity procedure within pediatric urology. STUDY DESIGN We administered a RedCap survey to the SPU membership, asking respondents to describe the level of autonomy afforded to trainees in various types of hypospadias repair (distal, midshaft, proximal, perineal) as measured by the Zwisch scale. The Zwisch scale describes the role of the attending in the attending-trainee relationship in a low-to-high trainee autonomy fashion: show and tell; active help; passive help; supervision only. RESULTS 177 of 761 (23%) unique recipients completed our survey and 174 of 177 (98%) of respondents felt that trainees should not perform hypospadias repair independently in practice without additional fellowship training. Among pediatric urologists who train residents, trainee autonomy as measured by the Zwisch scale decreased as the type of hypospadias repair moved from distal to proximal. DISCUSSION There was near unanimous agreement among respondents that urology trainees should not perform hypospadias repair in practice without additional pediatric urology fellowship training, and that current practice affords little trainee autonomy in hypospadias repair at the resident level. These findings introduce a new wrinkle into the issue of trainee autonomy: cases in which trainees perhaps should not have autonomy. Concurrently, the concern with such findings is that this intentional lack of autonomy may extend to other urologic procedures that one would expect trainees to be able to perform independently. CONCLUSION Urology trainees are not expected to be able to perform hypospadias in practice without additional training. This raises the question that there may be other such procedures in urology, and if so, should we as instructors, be forthcoming about the limitations of urology residency training to set appropriate trainee expectations?
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Affiliation(s)
- John M Masterson
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | | | - Peris R Castaneda
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Aurash Naser-Tavakolian
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Andrew L Freedman
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Naser-Tavakolian A, Masterson JM, Dallmer J, Bresee C, Zaliznyak M, Zhao H, Sandhu S, Garcia MM. Simultaneous Bladder Drainage via Suprapubic and Urethral Catheters: Which Drains More Completely and Why? J Surg Res (Houst) 2023; 6:317-322. [PMID: 37829933 PMCID: PMC10569114 DOI: 10.26502/jsr.10020316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Background Reconstructive urologists often place both a urethral and suprapubic catheter intraoperatively to prevent extravasation of undrained urine across anastomosis sutures. As no consensus exists on which catheter drains the bladder more completely, many surgeons leave one catheter to gravity drainage and cap the other postoperatively. We sought to identify differences in catheter urine outflow during dual bladder drainage with suprapubic and urethral catheters in postoperative urology patients. Methods Urine output (UOP) from transgender men who underwent Stage II Phalloplasty with urethral lengthening was retrospectively reviewed. Both 16 French urethral and suprapubic catheters were placed to gravity drainage postoperatively. Urine output from each catheter was recorded separately, twice daily. Mixed model regression modeling tested for differences in urine output by time of day (day/night) and activity status (Bedrest: Postop Day 0-2, Ambulatory: Postop Day 3+). Results The aggregate number of 12-hour shift urine output observations was 250 (125 for urethral and 125 for suprapubic catheters) across 14 inpatients. Suprapubic catheters had a mean 410 ml higher output than urethral catheters per 12-hour shift (p=0.002; 95% CI: 185, 636 ml). During daytime, Suprapubic catheters demonstrated higher UOP than urethral catheters per 12-hour shift (Estimated Difference: 464 ml; p=0.002; 95% CI: 211, 718 ml). During nighttime, a similar phenomenon was observed (Estimated Difference: 356 ml; p=0.009; 95% CI: 104, 606 ml). When comparing mean UOP from each catheter during the Bedrest Phase, suprapubic catheters averaged an estimated 295 ml higher UOP compared to urethral catheters per 12-hour shift with a trend toward statistical significance (p=0.052; 95% CI -3, 594 ml). During the Ambulatory Phase, mean suprapubic catheter UOP was an estimated 472 ml higher than urethral catheters per 12-hour shift (p=0.009; 95% CI 142, 802 ml). Conclusions Simultaneous bladder drainage with urethral and suprapubic catheters shows greater drainage from the suprapubic catheter (35% vs 65%). When using two catheters, both can be placed to gravity to maximize bladder drainage as the suprapubic catheter can drain residual urine not adequately drained by the urethral catheter.
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Affiliation(s)
| | - John M Masterson
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jeremiah Dallmer
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Catherine Bresee
- Biostatistics Shared Resources, Cedars-Sinai Samuel Oschin Comprehensive Cancer Center, Los Angeles, CA, USA
| | | | | | - Sandeep Sandhu
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Maurice M Garcia
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Urology and Department of Anatomy, University of California San Francisco, CA, USA
- Cedars-Sinai Transgender Surgery and Health Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Zaliznyak M, Isaacson D, Duralde E, Gaither TW, Naser-Tavakolian A, Bresee C, Stelmar J, Yuan N, Topp K, Garcia MM. Anatomic maps of erogenous sensation and pleasure in the penis: are there difference between circumcised and uncircumcised men? J Sex Med 2023; 20:253-259. [PMID: 36763960 DOI: 10.1093/jsxmed/qdac032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/05/2022] [Accepted: 11/10/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND The effects of male circumcision on sexual function remain controversial. Heterogeneity across previous studies and low-quality scientific evidence have resulted in poor understanding of the effects of circumcision on erogenous sensation of the penis and orgasm function. AIM In this study we sought to describe and assess differences in erogenous genital sensation and reported orgasm function in circumcised compared with uncircumcised men. METHODS Adult male subjects who were recruited on a paid anonymous online survey platform were shown illustrations of 12 anatomic regions of the penis. Subjects were prompted to designate regions as pleasurable when touched during partnered sex and to rate each on a 1-10 scale, with higher erogeneity scores correlating with greater pleasure. Subjects were also asked to characterize their orgasms across 6 experiential domains. OUTCOMES Outcomes were differences between circumcised and uncircumcised men in the probabilities that regions would be designated as pleasurable, average pleasure scores, and self-reported orgasm parameters. RESULTS In total, 227 circumcised (mean [SD] age 46.6 [17.7] years) and 175 uncircumcised men (47.8 [18.1] years) completed the survey. There were no significant differences in average ratings across all regions between circumcised and uncircumcised men. However, significantly more circumcised men reported preferences for the tip of the penis (38% vs 17%, P = .02) and the middle third of the ventral penile shaft (63% vs 48%, P = .04). Additionally, there were no significant differences in orgasm quality and function across all queried domains between circumcised and uncircumcised cohorts. CLINICAL IMPLICATIONS Our findings suggest that circumcision does not change how men describe erogenous genital sensation or how they experience orgasm. STRENGTHS AND LIMITATIONS In this study we expanded upon existing literature regarding comparison of sexual function in circumcised and uncircumcised men in its scale and investigation of diverse domains. Limitations include the survey format of data collection. CONCLUSION We found no differences in reported erogenous ratings or orgasm function between circumcised and uncircumcised men. These findings suggest that male circumcision does not negatively impact penile erogeneity or orgasm function.
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Affiliation(s)
- Michael Zaliznyak
- Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Dylan Isaacson
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Erin Duralde
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Thomas W Gaither
- Department of Urology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | | | - Catherine Bresee
- Biostatistics & Bioinformatics Core, Cedars-Sinai Samuel Oschin Comprehensive Cancer Center, Los Angeles, CA, United States
| | - Jenna Stelmar
- Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Cedars-Sinai Transgender Surgery and Health Program, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Nance Yuan
- Nance Yuan, MD Plastic Surgery, Los Angeles, CA, United States
| | - Kimberly Topp
- Department of Physical Therapy and Rehabilitation Science, University of California San Francisco, San Francisco, CA, United States
| | - Maurice M Garcia
- Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Cedars-Sinai Transgender Surgery and Health Program, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States.,Department of Urology and Anatomy, University of California San Francisco, San Francisco, CA, United States
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Masterson JM, Luu M, Naser-Tavakolian A, Freedland SJ, Sandler H, Zumsteg ZS, Daskivich TJ. Concurrent prognostic utility of lymph node count and lymph node density for men with pathological node-positive prostate cancer. Prostate Cancer Prostatic Dis 2023:10.1038/s41391-022-00635-1. [PMID: 36600045 DOI: 10.1038/s41391-022-00635-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/05/2022] [Accepted: 12/09/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND While both the number (+LN) and density (LND) of metastatic lymph nodes on radical prostatectomy lymphadenectomy predict mortality in prostate cancer, the independent impact of each on overall mortality (OM) is unknown. METHODS We sampled men who underwent radical prostatectomy and lymphadenectomy between 2004 and 2013 from the National Cancer Database. Multivariable Cox proportional hazards analysis with restricted cubic spline was used to assess the non-linear association of +LN count and LND with OM. RESULTS Of 229,547 men in our sample, 3% (n = 7507) had +LNs, of which 89% had 1-3 +LN and 11% had ≥4 +LN. In multivariable Cox analysis across all patients, OM increased with each additional +LN up to four (HR 1.14, 95%CI 1.06-1.23 per node), with no increase beyond 4 +LN. LND was an independent predictor of OM (HR 1.09, 95%CI 1.06-1.12 per 10% increase). However, after excluding patients with inadequate nodal sampling (<5 LN examined), the variation in OM explained by LND was negligible for patients with ≤3 +LN. In men with 1, 2, and 3 +LN, there was a 0.28%, 0.02%, and 0.50% increase in OM for each 10% increase in LND, compared with 1.9% and 1.6% for men with 4 or 5+ LNs. CONCLUSIONS While +LN count and LND independently predict OM, the impact of LND is negligible in men with ≤3 +LN, who comprise the vast majority of men with +LN. Pathological nodal staging should primarily rely on LN count rather than LND.
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Affiliation(s)
- John M Masterson
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael Luu
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Aurash Naser-Tavakolian
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephen J Freedland
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Section of Urology, Durham VA Medical Center, Durham, NC, USA
| | - Howard Sandler
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Zachary S Zumsteg
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Timothy J Daskivich
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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8
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Naser-Tavakolian A, Masterson J, Dallmer J, Bresee C, Zhao H, Garcia M. MP22-03 URETHRAL CATHETER VS SUPRAPUBIC CATHETER: WHICH DRAINS MORE COMPLETELY AND WHY? J Urol 2022. [DOI: 10.1097/ju.0000000000002561.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Naser-Tavakolian A, Gale R, Luu M, Venkataramana A, Khodyakov D, Posadas E, Sandler H, Anger J, Spiegel B, Freedland S, Daskivich T. MP31-14 VARIATION IN COMMUNICATION OF SIDE EFFECTS IN PROSTATE CANCER TREATMENT CONSULTATIONS. J Urol 2022. [DOI: 10.1097/ju.0000000000002580.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Kuhlmann PK, Chen M, Luu M, Naser-Tavakolian A, Kim HL, Saouaf R, Daskivich TJ. Predictors of disparity between targeted and in-zone systematic cores during transrectal MR/US-fusion prostate biopsy. Urol Oncol 2022; 40:162.e1-162.e7. [DOI: 10.1016/j.urolonc.2021.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 11/16/2021] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
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Ghodoussipour S, Naser-Tavakolian A, Cameron B, Mitra AP, Miranda G, Cai J, Bhanvadia S, Aron M, Desai M, Gill I, Schuckman A, Daneshmand S, Djaladat H. Internal audit of an enhanced recovery after surgery protocol for radical cystectomy. World J Urol 2020; 38:3131-3137. [PMID: 32112242 DOI: 10.1007/s00345-020-03135-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 02/09/2020] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To perform an internal audit 5 years after implementation of our enhanced recovery after surgery (ERAS) protocol for patients undergoing radical cystectomy and to investigate the importance of physician driven compliance on outcomes. METHODS Using a prospectively maintained database, 472 consecutive patients were identified who underwent radical cystectomy with ERAS from July 2013 to July 2017. Compliance was measured by a Composite Compliance Score (CCS) generated as a percentage of 16 interventions. Patients with higher than median compliance were compared to patients with lower compliance. The primary outcome was length of stay. Secondary outcomes included complication and readmission rates. Multivariable regressions were used to control for differences between groups. RESULTS In 2013, median CCS was 81% and subsequently ranged from 81 to 88%. Five-year median CCS was 88%. Patients with higher compliance (CCS ≥ 88%, n = 262), as compared to those with lower compliance (CCS < 88%, n = 210), were younger (median 70.3 vs 72.7 years, p = 0.047), healthier (ASA3-4 81% vs 89.9%, p = 0.007), received more orthotopic diversions (59.2% vs 37.6%, p < 0.0001), more often had open surgery (78.5% vs 51.9%, p < 0.0001) and had shorter median operative times (5.5 vs 6.3 h, p = 0.005). Median length of stay was 4 days. Higher compliance was associated with shorter hospital stays (β = - 0.85, 95% CI - 1.62 to - 0.07) and decreased 30-day readmissions (OR 0.58, 95% CI 0.35-0.96). CONCLUSIONS Greater ERAS compliance was achieved in younger and healthier patients. Patients with greater compliance had a decreased length of stay by almost 1 day and reduced odds of 30-day readmissions.
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Affiliation(s)
- Saum Ghodoussipour
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
| | - Aurash Naser-Tavakolian
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Brian Cameron
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Anirban P Mitra
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Gus Miranda
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Jie Cai
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Sumeet Bhanvadia
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Monish Aron
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Mihir Desai
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Inderbir Gill
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Anne Schuckman
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Siamak Daneshmand
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Hooman Djaladat
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
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Ghodoussipour S, Naser-Tavakolian A, Cameron B, Miranda G, Cai J, Pearce S, Bhanvadia S, Schuckman A, Daneshmand S, Djaladat H. Internal audit of an enhanced recovery after surgery for radical cystectomy. Clin Nutr ESPEN 2019. [DOI: 10.1016/j.clnesp.2019.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Naser-Tavakolian A, Jennelle R, Yoo S, Bian S, Matsuo K, Ye J, Pham A, Ragab O. Workflow Efficiency of High-Dose-Rate Cervical Brachytherapy in the Operating Room versus Ambulatory Setting at a Safety Net Hospital. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.1724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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15
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Marques C, Naser-Tavakolian A, Timoteo M, Sheth P, Nelson M, Ballas L, Ragab O, Ye J. Evaluating the Utility of Early Surveillance Mammography Following Post-Lumpectomy Radiation in Breast Cancer Patients: Comparison of a Safety-Net Hospital and an Academic-Based Hospital. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.1979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Naser-Tavakolian A, Tran C, Timoteo M, Chiu R, Ballas L. Novel Treatment Setup for Urethral Cancer: Use of the Prone Technique for Radiotherapy of the Penis. Case Rep Oncol 2018; 11:268-275. [PMID: 29867434 PMCID: PMC5981624 DOI: 10.1159/000488935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/03/2018] [Indexed: 11/19/2022] Open
Abstract
Urethral cancer (UC) is a rare malignancy with a poor prognosis. Since local recurrence is common and associated with morbidity, case series have reported on the use of adjuvant radiotherapy. Radiotherapy treatment setup for malignancies of the penis can be challenging because of variability in anatomic positioning. This variability can lead to lack of reproducibility. We propose a novel external beam radiotherapy technique for the treatment of UC: prone positioning. This technique has been used to treat breast cancers successfully and can be used to treat any variety of penile malignancies. We present 2 patients who were treated using this positioning.
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Affiliation(s)
- Aurash Naser-Tavakolian
- Department of Radiation Oncology, Keck School of Medicine of USC, USC Norris Comprehensive Cancer Center, Los Angeles, California, USA
| | - Cindy Tran
- Michigan State University College of Human Medicine, East Lansing, Michigan, USA
| | - Marissa Timoteo
- Department of Radiation Oncology, Keck School of Medicine of USC, USC Norris Comprehensive Cancer Center, Los Angeles, California, USA
| | - Raymond Chiu
- Department of Radiation Oncology, Keck School of Medicine of USC, USC Norris Comprehensive Cancer Center, Los Angeles, California, USA
| | - Leslie Ballas
- Department of Radiation Oncology, Keck School of Medicine of USC, USC Norris Comprehensive Cancer Center, Los Angeles, California, USA
- *Leslie Ballas, MD, Department of Radiation Oncology, Keck School of Medicine of USC, USC Norris Comprehensive Cancer Center, 1441 Eastlake Avenue, Los Angeles, CA 90033 (USA), E-Mail
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Chauhan J, Chen SE, Fenstermacher KJ, Naser-Tavakolian A, Reingewertz T, Salmo R, Lee C, Williams E, Raje M, Sundberg E, DeStefano JJ, Freire E, Fletcher S. Synthetic, structural mimetics of the β-hairpin flap of HIV-1 protease inhibit enzyme function. Bioorg Med Chem 2015; 23:7095-109. [PMID: 26474665 DOI: 10.1016/j.bmc.2015.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 08/20/2015] [Accepted: 09/03/2015] [Indexed: 01/11/2023]
Abstract
Small-molecule mimetics of the β-hairpin flap of HIV-1 protease (HIV-1 PR) were designed based on a 1,4-benzodiazepine scaffold as a strategy to interfere with the flap-flap protein-protein interaction, which functions as a gated mechanism to control access to the active site. Michaelis-Menten kinetics suggested our small-molecules are competitive inhibitors, which indicates the mode of inhibition is through binding the active site or sterically blocking access to the active site and preventing flap closure, as designed. More generally, a new bioactive scaffold for HIV-1PR inhibition has been discovered, with the most potent compound inhibiting the protease with a modest K(i) of 11 μM.
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Affiliation(s)
- Jay Chauhan
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, 20 N. Pine St., Baltimore, MD 21201, USA
| | - Shen-En Chen
- Department of Biology, Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, USA
| | - Katherine J Fenstermacher
- Department of Cell Biology & Molecular Genetics, University of Maryland, College Park, MD 20742, USA
| | - Aurash Naser-Tavakolian
- Department of Biology, Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, USA
| | - Tali Reingewertz
- Department of Microbiology and Immunology, University of Maryland School of Medicine, 725 West Lombard St., Baltimore, MD 21201, USA
| | - Rosene Salmo
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, 20 N. Pine St., Baltimore, MD 21201, USA
| | - Christian Lee
- PharmD Program, University of Maryland School of Pharmacy, 20 N. Pine St., Baltimore, MD 21201, USA
| | - Emori Williams
- Vivien T Thomas Medical Arts Academy, 100 N Calhoun St., Baltimore, MD 21223, USA
| | - Mithun Raje
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, 20 N. Pine St., Baltimore, MD 21201, USA
| | - Eric Sundberg
- Department of Microbiology and Immunology, University of Maryland School of Medicine, 725 West Lombard St., Baltimore, MD 21201, USA
| | - Jeffrey J DeStefano
- Department of Cell Biology & Molecular Genetics, University of Maryland, College Park, MD 20742, USA
| | - Ernesto Freire
- Department of Biology, Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, USA
| | - Steven Fletcher
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, 20 N. Pine St., Baltimore, MD 21201, USA; University of Maryland Greenebaum Cancer Center, 22 S. Greene St., Baltimore, MD 21201, USA.
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Thanigaimalai P, Konno S, Yamamoto T, Koiwai Y, Taguchi A, Takayama K, Yakushiji F, Akaji K, Chen SE, Naser-Tavakolian A, Schön A, Freire E, Hayashi Y. Development of potent dipeptide-type SARS-CoV 3CL protease inhibitors with novel P3 scaffolds: design, synthesis, biological evaluation, and docking studies. Eur J Med Chem 2013; 68:372-84. [PMID: 23994330 PMCID: PMC7115411 DOI: 10.1016/j.ejmech.2013.07.037] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 07/17/2013] [Accepted: 07/20/2013] [Indexed: 01/17/2023]
Abstract
We report the design and synthesis of a series of dipeptide-type inhibitors with novel P3 scaffolds that display potent inhibitory activity against SARS-CoV 3CLpro. A docking study involving binding between the dipeptidic lead compound 4 and 3CLpro suggested the modification of a structurally flexible P3 N-(3-methoxyphenyl)glycine with various rigid P3 moieties in 4. The modifications led to the identification of several potent derivatives, including 5c-k and 5n with the inhibitory activities (Ki or IC50) in the submicromolar to nanomolar range. Compound 5h, in particular, displayed the most potent inhibitory activity, with a Ki value of 0.006 μM. This potency was 65-fold higher than the potency of the lead compound 4 (Ki=0.39 μM). In addition, the Ki value of 5h was in very good agreement with the binding affinity (16 nM) observed in isothermal titration calorimetry (ITC). A SAR study around the P3 group in the lead 4 led to the identification of a rigid indole-2-carbonyl unit as one of the best P3 moieties (5c). Further optimization showed that a methoxy substitution at the 4-position on the indole unit was highly favorable for enhancing the inhibitory potency.
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Affiliation(s)
- Pillaiyar Thanigaimalai
- Department of Medicinal Chemistry, Tokyo University of Pharmacy and Life Sciences, Tokyo 192-0392, Japan
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Thanigaimalai P, Konno S, Yamamoto T, Koiwai Y, Taguchi A, Takayama K, Yakushiji F, Akaji K, Kiso Y, Kawasaki Y, Chen SE, Naser-Tavakolian A, Schön A, Freire E, Hayashi Y. Design, synthesis, and biological evaluation of novel dipeptide-type SARS-CoV 3CL protease inhibitors: structure-activity relationship study. Eur J Med Chem 2013; 65:436-47. [PMID: 23747811 PMCID: PMC7115367 DOI: 10.1016/j.ejmech.2013.05.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 04/20/2013] [Accepted: 05/07/2013] [Indexed: 11/28/2022]
Abstract
This work describes the design, synthesis, and evaluation of low-molecular weight peptidic SARS-CoV 3CL protease inhibitors. The inhibitors were designed based on the potent tripeptidic Z-Val-Leu-Ala(pyrrolidone-3-yl)-2-benzothiazole (8; Ki = 4.1 nM), in which the P3 valine unit was substituted with a variety of distinct moieties. The resulting series of dipeptide-type inhibitors displayed moderate to good inhibitory activities against 3CLpro. In particular, compounds 26m and 26n exhibited good inhibitory activities with Ki values of 0.39 and 0.33 μM, respectively. These low-molecular weight compounds are attractive leads for the further development of potent peptidomimetic inhibitors with pharmaceutical profiles. Docking studies were performed to model the binding interaction of the compound 26m with the SARS-CoV 3CL protease. The preliminary SAR study of the peptidomimetic compounds with potent inhibitory activities revealed several structural features that boosted the inhibitory activity: (i) a benzothiazole warhead at the S1′ position, (ii) a γ-lactam unit at the S1-position, (iii) an appropriately hydrophobic leucine moiety at the S2-position, and (iv) a hydrogen bond between the N-arylglycine unit and a backbone hydrogen bond donor at the S3-position.
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Affiliation(s)
- Pillaiyar Thanigaimalai
- Department of Medicinal Chemistry, Tokyo University of Pharmacy and Life Sciences, Tokyo 192-0392, Japan
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