Racial and Ethnic Variation in Receipt and Intensity of Active Surveillance for Older Patients With Localized Prostate Cancer

INTRODUCTION

The use of active surveillance (AS) for prostate cancer is increasing, and racial disparities have been identified in its implementation. We investigated differences by race and ethnicity in the utilization and intensity of AS by race and ethnicity among older men with low- and favorable intermediate-risk prostate cancer, with particular focus on the integration of multiparametric MRI (mpMRI) into AS protocols.

METHODS

Using the Surveillance, Epidemiology, and End Results and Medicare fee-for-service linked database, we identified a cohort of men diagnosed between 2010 and 2017 with low- or favorable intermediate-risk prostate cancer. The odds of receiving AS were compared by patient race and ethnicity using multivariable logistic regression models, while the rates of usage of PSA tests, biopsy, and mpMRI within 2 years of diagnosis among men on AS were assessed using multivariable Poisson regression models.

RESULTS

Our cohort included 33,542 men. The proportion of men with low-risk disease who underwent AS increased from 29.5% in 2010 to 51.7% in 2017, while the proportion among men with favorable intermediate disease grew from 11.4% to 17.2%. Hispanic (odds ratio [OR] = 0.68, 95% CI 0.58-0.79) and non-Hispanic Black men (OR = 0.78, 95% CI 0.68-0.89) were less likely to receive AS than non-Hispanic White men for low-risk disease, while non-Hispanic Black men were more likely to receive AS for favorable intermediate disease (OR = 1.21, 95% CI 1.04-1.39). Non-Hispanic Black men receiving AS underwent prostate MRI at a lower rate compared to non-Hispanic White men, regardless of whether they had low-risk (incidence rate ratio = 0.77, 95% CI 0.61-0.97) or favorable intermediate-risk (incidence rate ratio = 0.61, 95% CI 0.44-0.83) disease, respectively.

CONCLUSIONS

The overall adoption of AS for low-risk prostate cancer increased among Medicare fee-for-service beneficiaries. However, a significant disparity exists for non-Hispanic Black men, as they exhibit lower rates of AS utilization. Moreover, non-Hispanic Black men are less likely to have access to novel technologies, such as mpMRI, as part of their AS protocols.

Functional Outcomes After Localized Prostate Cancer Treatment

Importance

Adverse outcomes associated with treatments for localized prostate cancer remain unclear.

Objective

To compare rates of adverse functional outcomes between specific treatments for localized prostate cancer.

Design, Setting, and Participants

An observational cohort study using data from 5 US Surveillance, Epidemiology, and End Results Program registries. Participants were treated for localized prostate cancer between 2011 and 2012. At baseline, 1877 had favorable-prognosis prostate cancer (defined as cT1-cT2bN0M0, prostate-specific antigen level <20 ng/mL, and grade group 1-2) and 568 had unfavorable-prognosis prostate cancer (defined as cT2cN0M0, prostate-specific antigen level of 20-50 ng/mL, or grade group 3-5). Follow-up data were collected by questionnaire through February 1, 2022.

Exposures

Radical prostatectomy (n = 1043), external beam radiotherapy (n = 359), brachytherapy (n = 96), or active surveillance (n = 379) for favorable-prognosis disease and radical prostatectomy (n = 362) or external beam radiotherapy with androgen deprivation therapy (n = 206) for unfavorable-prognosis disease.

Main Outcomes and Measures

Outcomes were patient-reported sexual, urinary, bowel, and hormone function measured using the 26-item Expanded Prostate Cancer Index Composite (range, 0-100; 100 = best). Associations of specific therapies with each outcome were estimated and compared at 10 years after treatment, adjusting for corresponding baseline scores, and patient and tumor characteristics. Minimum clinically important differences were 10 to 12 for sexual function, 6 to 9 for urinary incontinence, 5 to 7 for urinary irritation, and 4 to 6 for bowel and hormone function.

Results

A total of 2445 patients with localized prostate cancer (median age, 64 years; 14% Black, 8% Hispanic) were included and followed up for a median of 9.5 years. Among 1877 patients with favorable prognosis, radical prostatectomy was associated with worse urinary incontinence (adjusted mean difference, -12.1 [95% CI, -16.2 to -8.0]), but not worse sexual function (adjusted mean difference, -7.2 [95% CI, -12.3 to -2.0]), compared with active surveillance. Among 568 patients with unfavorable prognosis, radical prostatectomy was associated with worse urinary incontinence (adjusted mean difference, -26.6 [95% CI, -35.0 to -18.2]), but not worse sexual function (adjusted mean difference, -1.4 [95% CI, -11.1 to 8.3), compared with external beam radiotherapy with androgen deprivation therapy. Among patients with unfavorable prognosis, external beam radiotherapy with androgen deprivation therapy was associated with worse bowel (adjusted mean difference, -4.9 [95% CI, -9.2 to -0.7]) and hormone (adjusted mean difference, -4.9 [95% CI, -9.5 to -0.3]) function compared with radical prostatectomy.

Conclusions and Relevance

Among patients treated for localized prostate cancer, radical prostatectomy was associated with worse urinary incontinence but not worse sexual function at 10-year follow-up compared with radiotherapy or surveillance among people with more favorable prognosis and compared with radiotherapy for those with unfavorable prognosis. Among men with unfavorable-prognosis disease, external beam radiotherapy with androgen deprivation therapy was associated with worse bowel and hormone function at 10-year follow-up compared with radical prostatectomy.

Understanding the Termination of Urologic Cancer Clinical Trials: Insights and Challenges

PURPOSE

Clinical trials are valuable evidence for managing urologic malignancies. Early termination of clinical trials is associated with a waste of resources and may substantially affect patient care. We sought to study the termination rate of urologic cancer clinical trials and identify factors associated with trial termination.

METHODS

A cross-sectional search of ClinicalTrials.gov identified completed and terminated kidney, prostate, and bladder cancer clinical trials started. Trials were assessed for reasons for termination. Multivariable analyses were conducted to determine the significant factors associated with the termination.

RESULTS

Between 2000 and 2020, 9,145 oncology clinical trials were conducted, of which 11.30% (n = 1,033) were urologic cancer clinical trials. Of the urologic cancer clinical trials, 25.38% (n = 265) were terminated, with low patient accrual being the most common reason for termination, 52.9% (n = 127). Multivariable analysis showed that only the university funding source odds ratio (OR) of 2.20 (95% CI, 1.45 to 3.32), single-center studies OR of 2.11 (95% CI, 1.59 to 2.81), and sample size of <50 were significant predictors of clinical trial termination OR of 5.26 (95% CI, 3.85 to 7.69); all P values are <.001.

CONCLUSION

The termination rate of urologic cancer clinical trials was 25%, with low accrual being the most frequently reported reason. Trials funded by a university, single-center trials, and small trials (sample size <50) were associated with early termination. A better understanding of these factors might help researchers, funding agencies, and other stakeholders prioritize resource allocations for multicenter trials that aim to recruit a sufficient number of patients.

Trends, Cost, and Predictors of Local Hemostatics Use in Major Urological Surgery

INTRODUCTION

The national usage and cost trends associated with hemostatic agents in major urologic procedures remain unknown. This study aims to describe the trends, costs, and predictors of local hemostatic use in major urologic surgeries.

METHODS

We utilized the Premier Healthcare Database to analyze 385,261 patient encounters between 2000 and 2020. Our primary objective was to describe the usage patterns of topical hemostatic agents in open and laparoscopic/robotic major urological surgeries. The data from the last 5 years (2015-2020) were used to characterize specific cost trends, and multivariable regression analysis was performed to identify predictors of hemostatic agent use in relation to surgical approach, patient, and hospital characteristics.

RESULTS

By 2020, at least 1 topical hemostatic agent was used in 37.3% (95% CI: 35.5-39.1) of laparoscopic/robotic prostatectomies and 30.7% (95% CI: 24.2-37.1) of open prostatectomies; 60.8% (95% CI: 57.6-64.1) of laparoscopic/robotic partial nephrectomies and 55.9% (95% CI: 47.3-64.5) of open partial nephrectomies; 40.7% (95% CI: 36.9-44.3) of laparoscopic/robotic radical nephrectomies and 43.2% (95% CI: 38.8-47.6) of open radical nephrectomies; and 40.52% (95% CI: 35.02-46.02) of open radical cystectomies. For the 2015-2020 cohort, predictors for hemostatic agent use varied by surgery type and included gender, race, surgical approach, insurance coverage, geographical location, urbanicity, and attending volume. The cost of the hemostatic agent accounted for less than 1.6% of the total cost of hospitalization for each procedure.

CONCLUSIONS

The use of hemostatic agents in major urologic surgeries has grown over the past 2 decades. For all procedures, the specific cost of using a hemostatic agent constitutes a small fraction of the total hospitalization cost and does not vary significantly between open and laparoscopic/robotic approaches. Some patient, surgeon, and hospital characteristics are highly correlated with their use.

Projected Savings for Generic Oncology Drugs Purchased via Mark Cuban Cost Plus Drug Company Versus in Medicare

PURPOSE

Self-administered oncology drugs contribute disproportionately to Medicare Part D spending; prices often remain high even after generic entry. Outlets for low-cost drugs such as Mark Cuban Cost Plus Drug Company (MCCPDC) offer opportunities for decreased Medicare, Part D, and beneficiary spending. We estimate potential savings if Part D plans obtained prices such as those offered under the MCCPDC for seven generic oncology drugs.

METHODS

Using the 2020 Medicare Part D Spending dashboard, Q3-2022 Part D formulary prices, and Q3-2022 MCCPDC prices for seven self-administered generic oncology drugs, we estimated Medicare savings by replacing Q3-2022 Part D unit costs with costs under the MCCPDC plan.

RESULTS

We estimate potential savings of $661.8 million (M) US dollars (USD; 78.8%) for the seven oncology drugs studied. Total savings ranged from $228.1M USD (56.1%) to $2,154.5M USD (92.4%) compared with 25th and 75th percentiles of Part D plan unit prices. The median savings replacing Part D plan prices were abiraterone $338.0M USD, anastrozole $1.2M USD, imatinib 100 mg $15.6M USD, imatinib 400 mg $212.0M USD, letrozole $1.9M USD, methotrexate $26.7M USD, raloxifene $63.8M USD, and tamoxifen $2.6M USD. All 30-day prescription drug prices offered by MCCPDC generated cost savings except for three drugs offered at the 25th percentile Part D formulary pricing: anastrozole, letrozole, and tamoxifen.

CONCLUSION

Replacing current Part D median formulary prices with MCCPDC pricing could yield significant savings for seven generic oncology drugs. Individual beneficiaries could save nearly $25,200 USD per year for abiraterone or between $17,500 USD and $20,500 USD for imatinib. Notably, Part D cash-pay prices for abiraterone and imatinib under the catastrophic phase of coverage were still more expensive than baseline MCCPDC prices.

Adoption and Outcomes of Holmium Laser Enucleation of the Prostate in the United States

OBJECTIVE

To investigate the utilization of holmium laser enucleation of the prostate (HoLEP) using a large real-world cohort. We compare the safety, readmission, and retreatment rates of HoLEP to other widely used endoscopic surgical interventions for benign prostatic hyperplasia (BPH) including transurethral resection of the prostate (TURP), photoselective vaporization of the prostate, and prostatic urethral lift.

METHODS

Men who underwent endoscopic treatments for BPH from 2000 to 2019 were identified in the Premier Healthcare Database (n = 218,793). We compared the relative proportion of each procedure performed and annual physician volume data to identify trends in adoption and utilization. Readmission and retreatment rates were determined at both 30- and 90-days postoperation. Multivariable logistic regression was used to assess the association between procedure type and outcomes.

RESULTS

HoLEP accounted for 3.2% (n = 6967) of all the BPH procedures performed between 2000 and 2019 and increased from 1.1% of the procedures in 2008 to 4% in 2019. Patients undergoing HoLEP had lower odds of 90-days readmission compared to TURP (Odds ratio (OR) 0.87, p = 0.025). HoLEP had similar odds of retreatment compared to TURP at both 1-year (OR 0.96, p = 0.7) and 2-years (OR 0.98, p = 0.9), while patients undergoing photoselective vaporization of the prostate and prostatic urethral lift were more likely to retreat within 2-years (OR 1.20, P < 0.001; OR 1.87, P < 0.001).

CONCLUSION

HoLEP is a safe therapy for BPH with lower readmission and comparable retreatment rates to the gold standard TURP. Despite this, the utilization of HoLEP has lagged behind other endoscopic procedures and remains low.

Estimating the Impact of the Inflation Reduction Act on the Out-of-Pocket Costs for Medicare Beneficiaries With Advanced Prostate Cancer

INTRODUCTION

Combination systemic therapy for advanced prostate cancer has reduced mortality, but high out-of-pocket costs impose financial barriers for patients. The Inflation Reduction Act's $2,000 out-of-pocket spending cap for Medicare's prescription drug benefit (Part D) can potentially lower out-of-pocket spending for beneficiaries starting in 2025. This study aims to compare out-of-pocket spending for commonly prescribed regimens for advanced prostate cancer before and after implementation of the Inflation Reduction Act.

METHODS

Medication regimens constructed to treat metastatic, hormone-sensitive prostate cancer consisted of baseline androgen deprivation therapy with traditional chemotherapy, androgen receptor inhibitors, and androgen biosynthesis inhibitors. Using 2023 Medicare Part B prices and the Medicare Part D plan finder, we estimated annual out-of-pocket costs under current law and under the Inflation Reduction Act's redesigned standard Part D benefit.

RESULTS

Under current law, out-of-pocket costs for Part D drugs ranged from $464 to $11,336 per year. Under the Inflation Reduction Act, annual out-of-pocket costs for 2 regimens remained unchanged: androgen deprivation therapy with docetaxel and androgen deprivation therapy with abiraterone and prednisone. However, out-of-pocket costs for regimens using branded novel hormonal therapy were significantly lower under the 2025 law with potential savings estimated to be $9,336 (79.2%) for apalutamide, $9,036 (78.7%) for enzalutamide, and $8,480 (76.5%) for docetaxel and darolutamide.

CONCLUSIONS

The $2,000 spending cap introduced by the Inflation Reduction Act may significantly decrease out-of-pocket costs and reduce financial toxicity associated with advanced prostate cancer treatment, impacting an estimated 25,000 Medicare beneficiaries.

Use of Active Surveillance vs Definitive Treatment Among Men With Low- and Favorable Intermediate-Risk Prostate Cancer in the US Between 2010 and 2018

This cross-sectional study of data from the Surveillance, Epidemiology and End Results database assesses temporal trends in the use of active surveillance and watchful waiting vs definitive treatment in men with low- and favorable intermediate–risk prostate cancer in the US between 2010 and 2018.

Impact of Magnetic Resonance Imaging Targeting on Pathologic Upgrading and Downgrading at Prostatectomy: A Systematic Review and Meta-analysis

CONTEXT

The evidence supporting multiparametric magnetic resonance imaging (MRI) targeting for biopsy is nearly exclusively based on biopsy pathologic outcomes. This is problematic, as targeting likely allows preferential identification of small high-grade areas of questionable oncologic significance, raising the likelihood of overdiagnosis and overtreatment.

OBJECTIVE

To estimate the impact of MRI-targeted, systematic, and combined biopsies on radical prostatectomy (RP) grade group concordance.

EVIDENCE ACQUISITION

PubMed MEDLINE and Cochrane Library were searched from July 2018 to January 2022. Studies that conducted systematic and MRI-targeted prostate biopsies and compared biopsy results with pathology after RP were included. We performed a meta-analysis to assess whether pathologic upgrading and downgrading were influenced by biopsy type and a net-benefit analysis using pooled risk difference estimates.

EVIDENCE SYNTHESIS

Both targeted only and combined biopsies were less likely to result in upgrading (odds ratio [OR] vs systematic of 0.70, 95% confidence interval [CI] 0.63-0.77, p < 0.001, and 0.50, 95% CI 0.45-0.55, p < 0.001), respectively). Targeted only and combined biopsies increased the odds of downgrading (1.24 (95% CI 1.05-1.46), p = 0.012, and 1.96 (95% CI 1.68-2.27, p < 0.001) compared with systematic biopsies, respectively. The net benefit of targeted and combined biopsies is 8 and 7 per 100 if harms of up- and downgrading are considered equal, but 7 and -1 per 100 if the harm of downgrading is considered twice that of upgrading.

CONCLUSIONS

The addition of MRI-targeting results in lower rates of upgrading as compared to systematic biopsy at RP (27% vs 42%). However, combined MRI-targeted and systematic biopsies are associated with more downgrading at RP (19% v 11% for combined vs systematic). Strong heterogeneity suggests further research into factors that influence the rates of up- and downgrading and that distinguishes clinically relevant from irrelevant grade changes is needed. Until then, the benefits and harms of combined MRI-targeted and systematic biopsies cannot be fully assessed.

PATIENT SUMMARY

We reviewed the ability of magnetic resonance imaging (MRI)-targeted biopsies to predict cancer grade at prostatectomy. We found that combined MRI-targeted and systematic biopsies result in more cancers being downgraded than systematic biopsies.

The lived experience of prostate cancer: 10-year survivor perspectives following contemporary treatment of localized prostate cancer

PURPOSE

Studies relying on standardized instruments to measure patient-centered harms and benefits of cancer treatment may fail to capture important elements of the lived experience of cancer patients. Further, qualitative studies on the survivorship experience of men with localized prostate cancer (PCa) are limited. We sought to explore the early experience, long-term experience, and advice provided for others among long-term survivors of localized PCa.

METHODS

Semi-structured qualitative interviews with a subset (n = 66) of respondents to a survey of 10-year PCa survivors who underwent active surveillance, radical prostatectomy, or radiotherapy. Topics included early and long-term experiences and advice to other men and physicians.

RESULTS

Immediately after treatment, men were mostly satisfied with radiation and active surveillance due to remaining whole and avoiding surgical removal of the prostate. Meanwhile, men treated with surgery felt relieved by the removal of cancer. Some early negative perception was related to short-term anxiety, particularly among men who underwent active surveillance. Long-term experiences included accepting the trade-offs of urinary and sexual side effects with survival. Most men fared well financially, some had strengthened relationships, and many reported greater appreciation and compassion. Men provided essential advice to other men and physicians on the importance of gathering detailed information on treatments and establishing a strong relationship with physicians.

CONCLUSIONS

Long-term survivors of localized PCa generally do well by accepting the long-term effects of contemporary treatments, experiencing strengthened relationships, and developing a better overall life approach.

IMPLICATIONS FOR CANCER SURVIVORS

We provide useful perspectives and insights for men opting to use current-day treatments for localized PCa.

Implementation of a comprehensive prehabilitation program for patients undergoing radical cystectomy

BACKGROUND

Coordinated preoperative optimization programs for radical cystectomy (RC) are limited and non-comprehensive. We evaluated the feasibility and acceptability of a coordinated, multi-faceted prehabilitation program for RC patients at a high-volume bladder cancer referral center.

METHODS

We performed a narrative literature review for prehabilitation in bladder cancer management as of December 1, 2020, with specific emphasis on examining higher-level evidence sources. We selected domains with the highest level of evidence and recruited a multidisciplinary team of experts to design our program. We implemented a comprehensive prehabilitation program with a pre-defined order set as standard of care for all patients undergoing RC beginning February 1, 2021. Demographic and clinicopathologic data were collected prospectively. Rates of adherence to the prehabilitation program services were analyzed using Stata version 13.

RESULTS

A total of 82 patients were enrolled between February - December 2021, of which 67 (81%) had undergone RC at data cutoff. Mean age was 68 years (SD 11) and 63 (76%) identified as male. Neoadjuvant chemotherapy (NAC) was utilized in 48 (59%) patients. The mean Charlson Comorbidity Index was 3.8 (SD 2.3). 100% of patients were screened for malnutrition, with 82% consuming nutritional supplements. Fifty-two percent of patients attended physical therapy pre-op. The 30-day and 30- to 90-day rates of complications were 56% and 40%, respectively. Resource length of stay (RLOS) declined after implementation of prehabilitation.

CONCLUSIONS

Implementation of a comprehensive prehabilitation program at a high-volume bladder cancer referral center is feasible and has a modest effect on resource consumption and complications in our early experience.

Race and prostate cancer: genomic landscape

In the past 20 years, new insights into the genomic pathogenesis of prostate cancer have been provided. Large-scale integrative genomics approaches enabled researchers to characterize the genetic and epigenetic landscape of prostate cancer and to define different molecular subclasses based on the combination of genetic alterations, gene expression patterns and methylation profiles. Several molecular drivers of prostate cancer have been identified, some of which are different in men of different races. However, the extent to which genomics can explain racial disparities in prostate cancer outcomes is unclear. Future collaborative genomic studies overcoming the underrepresentation of non-white patients and other minority populations are essential.

Intensity of observation with active surveillance or watchful waiting in men with prostate cancer in the United States

BACKGROUND

Population-based studies assessing various active surveillance (AS) protocols for prostate cancer, to date, have inferred AS participation by the lack of definitive treatment and use of post-diagnostic testing. This is problematic as evidence suggests that most men do not adhere to AS protocols. We sought to develop a novel method of identifying men on AS or watchful waiting (WW) independent of post-diagnostic testing and aimed to identify possible predictors of follow-up intensity in men on AS/WW.

METHODS

A predictive model was developed using SEER watchful waiting data to identify men ≥66 years on AS between 2010-2015, irrespective of post-diagnostic testing, and applied to SEER-Medicare database. AS intensity among different variables including age, prostate-specific antigen (PSA) level, number of total and positive biopsy cores, Charlson comorbidity index, race (Black vs. non-Black), US census region, and county poverty, income, and education levels were compared using multivariable regression analyses for PSA testing, surveillance biopsy, and magnetic resonance imaging (MRI).

RESULTS

A total of 2238 men were identified as being on AS. Of which, 81%, 33%, and 10% had a PSA test, surveillance biopsy, and MRI scan within 1-2 years, respectively. On multivariable analyses, Black men were less likely to have a PSA test (adjusted rate ratio [ARR] 0.60, 95% CI: 0.53-0.69), MRI scan (ARR 0.40, 95% CI: 0.24-0.68), and surveillance biopsy (ARR 0.71, 95% CI: 0.55-0.92) than non-Black men. Men within the highest income quintile were more likely to undergo PSA test (ARR 1.16, 95% CI: 1.05-1.27) and MRI scan (ARR 1.60, 95% CI 1.15-2.27) compared to men with the lowest income.

CONCLUSIONS

Black men and men with lower incomes on AS underwent less rigorous monitoring. Further study is needed to understand and ameliorate differences in AS rigor stemming from sociodemographic differences.

A comparative population-based analysis of peritoneal carcinomatosis in patients undergoing robotic-assisted and open radical cystectomy

PURPOSE

To compare the population-based incidence of peritoneal carcinomatosis following open (ORC) vs. robotic-assisted radical cystectomy (RARC).

METHODS

Using the Surveillance, Epidemiology and End Results Program (SEER)-Medicare linked data, we identified 1,621 patients who underwent radical cystectomy for bladder cancer during 2009 and 2014; 18.1% (n = 294) and 81.9% (n = 1327) underwent RARC and ORC, respectively. We subsequently evaluated the rates of peritoneal carcinomatosis at 6, 12, and 24 months following surgery. Multivariable proportional hazards regression was performed to determine factors associated with development of peritoneal carcinomatosis.

RESULTS

Patients who underwent RARC vs. ORC were more likely to be male (p = 0.04); however, age at diagnosis, race, comorbidities, education, and marital status (all p > 0.05) did not differ by surgical approaches. Our findings showed that there were no significant differences in the rates of peritoneal carcinomatosis between ORC and RARC at 6, 12, and 24 months. In adjusted analyses, factors associated with peritoneal carcinomatosis were advanced N stage (N0 versus N2/3: HR 0.30, 95% CI 0.16-0.55, p < 0.01), preoperative hydronephrosis (HR 1.70, 95% CI 1.09-2.65, p = 0.04), higher T stage (T1 versus T4: HR 0.34, 95% CI 0.15-0.79, p < 0.01; T2 versus T4: HR 0.39, 95% CI 0.20-0.76, p < 0.01), and use of neoadjuvant chemotherapy (HR 1.78, 95% CI 1.11-2.84, p < 0.01). However, RARC was not associated with peritoneal carcinomatosis (HR 1.36, 95% CI 0.78-2.35).

CONCLUSION

In this population-based analysis, we found no difference in peritoneal carcinomatosis between robotic or open approaches to radical cystectomy. These data should be reassuring to those utilizing robotic cystectomy.

Does neoadjuvant chemotherapy diminish the sex disparity in bladder cancer survival after radical cystectomy?

INTRODUCTION

Sex-specific survival disparities for bladder cancer outcomes after radical cystectomy (RC) have been demonstrated in several studies. However, these studies predate the widespread adoption of neoadjuvant chemotherapy (NAC). We evaluated the differences in sex-specific survival between patients who received NAC with those who did not, using a contemporary national outcomes database.

METHODS

The National Cancer Data Base was queried from 2004 to 2015 to identify subjects who underwent RC. Kaplan-Meier method with log-rank test was performed to compare all-cause mortality between men and women at each pathologic (p) TNM stage group: T1-4N0, N+ and M+ disease. Associations for all-cause mortality were identified using an adjusted Cox regression analysis, and our findings were confirmed with a subgroup analysis.

RESULTS

A total of 9,835 subjects (7,483 men and 2,532 women) were included in the analysis. Kaplan-Meier survival curves and Cox regression analysis demonstrated female sex was not associated with worse overall survival compared to males (HR 0.947, 95%CI 0.852-1.053, P = 0.947) in the overall cohort. Stratified by pT stage and node positivity, worse overall survival was seen in women with pT4 disease who did not receive NAC compared to men (5-year OS 9.6% women vs. 15.2% men, P < 0.001), but no sex-specific difference was seen across all groups in patients who received NAC. Subgroup multivariable analysis showed that female sex conferred a survival disadvantage for pT4 (HR 1.369, P = 0.026) disease only in patients who did not receive NAC.

CONCLUSIONS

In a contemporary cohort of subjects who underwent RC, administration of NAC narrows the sex survival-gap in advanced stage bladder cancer. Strategies to improve NAC usage in women should be adopted to overcome potential sex-specific differences such as delayed diagnosis, anatomic differences in higher stage disease, or altered tumor biology which may contribute to differences in oncologic outcomes.

Practice patterns of vasal reconstruction in a large United States cohort

We aimed to characterise diverse practice patterns for vasal reconstruction and to determine whether surgeon volume is associated with vasoepididymostomy performance at the time of reconstruction. We identified adult men who underwent vasal reconstruction from 2000 to 2020 in Premier Healthcare Database and determined patient, surgeon, cost and hospital characteristics for each procedure. We identified 3,494 men who underwent either vasovasostomy-alone (N = 2,595, 74.3%) or any-vasoepididymostomy (N = 899, 25.7%). The majority of providers (N = 487, 88.1%) performed only-vasovasostomy, 10 (1.8%) providers performed only-vasoepididymostomy and 56 (10.1%) providers performed both. Median total hospital charge of vasoepididymostomy was significantly higher than vasovasostomy ($39,163, interquartile range [IQR]$11,854-53,614 and $17,201, IQR$10,904-29,986, respectively). On multivariable regression, men who underwent procedures at nonacademic centres (OR 2.71, 95% CI 2.12-3.49) with higher volume surgeons (OR 11.60, 95% CI 8.65-16.00) were more likely to undergo vasoepididymostomy. Furthermore, men who underwent vasoepididymostomy were more likely to self-pay (OR 2.35, 95% CI 1.83-3.04, p < .001) and more likely had procedures in the Midwest or West region (OR 2.22, 95% CI 1.66-2.96 and OR 2.11, 95% CI 1.61-2.76, respectively; p < .001). High-volume providers have increased odds of performing vasoepididymostomy at the time of reconstruction but at a significantly higher cost. These data suggest possibly centralising reconstructive procedures among high-volume providers.

Prostate Cancer Screening for Gay Men in the United States

OBJECTIVES

To elucidate trends of prostate-cancer (PCa) screening in gay and bisexual men and assess the association of sexual orientation with PCa screening in the US.

METHODS

Data for men ≥ 40 years-old with no history of PCa were collected from the National Health Interview Survey for the years 2013, 2015, and 2018. Multivariable logistic regression models were created to determine the associations between sexual orientation and PCa screening and the discussion of advantages and disadvantages prior to PCa screening.

RESULTS

Gay men screened for prostate cancer were younger than their straight counterparts with a median age (IQR) of 58 years (52-66) versus 64 years (56-71). Gay men were more likely to have undergone a screening PSA test (OR 1.56; 95%CI 1.20-2.02) and discuss the advantages of PSA testing with the physician prior to the test (OR 1.64; 95% CI 1.22 - 2.21) when compared to straight men. In yearly analysis, gay men were more likely to have undergone screening in 2013 (OR 1.65, 95%CI 1.01-2.68) and 2015 OR 1.95, 95CI% 1.30-2.91), however, there was no difference when compared to straight men in 2018 (OR 1.32, 95%CI 0.85-2.04).

CONCLUSIONS

Gay men were screened for PCa at a younger age comparted to straight men. They were also more likely to have undergone PCa cancer screening than straight men between 2013-18. Further study is needed to better understand the role of sexual orientation in PCa screening and management.

Tissue-Based Biomarkers for the Risk Stratification of Men With Clinically Localized Prostate Cancer

Risk stratification of men with clinically localized prostate cancer has historically relied on basic clinicopathologic parameters such as prostate specific antigen level, grade group, and clinical stage. However, prostate cancer often behaves in ways that cannot be accurately predicted by these parameters. Thus, recent efforts have focused on developing tissue-based genomic tests that provide greater insights into the risk of a given patient's disease. Multiple tests are now commercially available and provide additional prognostic information at various stages of the care pathway for prostate cancer. Indeed, early evidence suggests that these assays may have a significant impact on patient and physician decision-making. However, the impact of these tests on oncologic outcomes remains less clear. In this review, we highlight recent advances in the use of tissue-based biomarkers in the treatment of prostate cancer and identify the existing evidence supporting their clinical use.

Variation in the Use of Active Surveillance for Low-Risk Prostate Cancer Across US Census Regions

Substantial geographic variation in healthcare practices exist. Active surveillance (AS) has emerged as a critical tool in the management of men with low-risk prostate cancer. Whether there have been regional differences in adoption is largely unknown. The SEER “Prostate with Watchful Waiting Database” was used to identify patients diagnosed with localized low-risk prostate cancer and managed with AS across US census regions between 2010 and 2016. Multivariable logistic regression models were used to determine the impact of region on undergoing AS and factors associated with AS use within each US census region. Between 2010 and 2016, the proportion of men managed with AS increased from 20.8% to 55.9% in the West, 11.5% to 50.0% in Northeast, 9.9% to 43.4% in the South and 15.1% to 56.2% in Midwest (p < 0.0001). On multivariable analysis, as compared to the West, men in all regions were less likely to undergo AS (p < 0.001). Black men in the West (OR 1.36, 95%CI 1.25–1.49) and Midwest (OR 1.62, 95%CI 1.35–1.95) were more likely to undergo AS, but less likely in Northeast (OR 0.80, 95%CI 0.69–0.92). Men with higher socioeconomic status (SES) were more likely to undergo AS in the West (OR 1.47, 95%CI 1.39–1.55), Northeast (OR 1.57, 95%CI 1.36–1.81), and South (OR 1.24, 95%CI 1.13–1.37) but not in the Midwest (OR 0.85, 95%CI 0.73–0.98). We found striking regional differences in the uptake of AS according to race and SES. Geography must be taken into consideration when assessing barriers to AS use.

Magnetic Resonance Imaging Radiomics-Based Machine Learning Prediction of Clinically Significant Prostate Cancer in Equivocal PI-RADS 3 Lesions

BACKGROUND

While Prostate Imaging Reporting and Data System (PI-RADS) 4 and 5 lesions typically warrant prostate biopsy and PI-RADS 1 and 2 lesions may be safely observed, PI-RADS 3 lesions are equivocal.

PURPOSE

To construct and cross-validate a machine learning model based on radiomics features from T₂ -weighted imaging (T₂ WI) of PI-RADS 3 lesions to identify clinically significant prostate cancer (csPCa), that is, pathological Grade Group ≥ 2.

STUDY TYPE

Single-center retrospective study.

POPULATION

A total of 240 patients were included (training cohort, n = 188, age range 43-82 years; test cohort, n = 52, age range 41-79 years). Eligibility criteria were 1) magnetic resonance imaging (MRI)-targeted biopsy between 2015 and 2020; 2) PI-RADS 3 index lesion identified on multiparametric MRI; (3) biopsy performed within 1 year of MRI. The percentages of csPCa lesions were 10.6% and 15.4% in the training and test cohorts, respectively.

FIELD STRENGTH/SEQUENCE

A 3 T; T₂ WI turbo-spin echo, diffusion-weighted spin-echo echo planar imaging, dynamic contrast-enhanced MRI with time-resolved T1-weighted imaging.

ASSESSMENT

Multislice volumes-of-interest (VOIs) were drawn in the PI-RADS 3 index lesions on T₂ WI. A total of 107 radiomics features (first-order histogram and second-order texture) were extracted from the segmented lesions.

STATISTICAL TESTS

A random forest classifier using the radiomics features as input was trained and validated for prediction of csPCa. The performance of the machine learning classifier, prostate specific antigen (PSA) density, and prostate volume for csPCa prediction was evaluated using receiver operating characteristic (ROC) analysis.

RESULTS

The trained random forest classifier constructed from the T₂ WI radiomics features good and statistically significant area-under-the-curves (AUCs) of 0.76 (P = 0.022) for prediction of csPCa in the test set. Prostate volume and PSA density showed moderate and nonsignificant performance (AUC 0.62, P = 0.275 and 0.61, P = 0.348, respectively) for csPCa prediction in the test set.

CONCLUSION

The machine learning classifier based on T₂ WI radiomic features demonstrated good performance for prediction of csPCa in PI-RADS 3 lesions.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY: 2.

Feasibility of in-office MRI-targeted partial gland cryoablation for prostate cancer: an IDEAL stage 2A study

Objectives

Cryoablation for prostate cancer is typically performed under general anaesthesia. We explore the safety, feasibility and costs of in-office MRI-targeted prostate partial gland cryoablation (PGC) under local anaesthesia. We hypothesise that an office-based procedure under local anaesthesia may yield greater patient convenience and lower health costs with similar outcomes to a general anaesthesia approach.

Design/participants/setting/interventions

Retrospective study of men diagnosed with clinically significant prostate cancer (grade group (GG) ≥2) who elected to undergo in-office PGC under local anaesthesia.

Main outcome measures

A total of 55 men with GG ≥2 prostate cancer underwent PGC under local anaesthesia, and 35 of 43 men (81.4%) who attained ≥6 months of follow-up post-treatment underwent MRI-targeted surveillance biopsy. We used MRI findings and targeted biopsy to characterise post-PGC oncological outcomes. Complications were categorised using Common Terminology Criteria for Adverse Events (CTCAE). Expanded Prostate Cancer Index-Clinical Practice was used to characterise urinary and sexual function scores at baseline, 4 and 9 months post-PGC. Time-driven activity-based costing was used to determine healthcare costs of in-office PGC.

Results

Five (9.1%) men experienced CTCAE score 3 adverse events. Urinary and sexual function did not change significantly from baseline to 4 months (p=0.20 and p=0.08, respectively) and 9 months (p=0.23 and p=0.67, respectively). Twenty-two men (62.9%) had no cancer or GG1 and 13 (37.1%) men had GG≥2 on post-PGC biopsy. Moreover, the median cost of in-office PGC was US$4,463.05 (range US$4,087.19–US7,238.16) with disposables comprising 69% of the cost.

Conclusions

In-office PGC is feasible under local anaesthesia with favourable functional outcome preservation and adverse events profile at significantly lower costs compared with a general anaesthesia approach.

The role of surgical experience in patient selection, surgical quality, and outcomes in robot-assisted radical cystectomy

BACKGROUND

Robot-assisted radical cystectomy (RARC) remains one of the most complex urological procedures. Due to regionalization of bladder cancer care, there is likely an imbalance in experience among urologists performing RARC. We sought to describe changes in patient selection, surgical quality surrogates and rates of complications in relation to surgical experience.

METHODS

We retrospectively reviewed 409 consecutive patients with bladder cancer who underwent RARC between 2006 and 2017 by a single surgeon. The cohort was divided into 4 quartiles (Q1-Q4) according to surgical experience, based on the chronologic order at which RARC was performed. Baseline, perioperative and pathologic characteristics of patients were compared among the 4 groups. 30-day and 90-day complications were assessed using the Clavien-Dindo system. The association between surgical experience (quartile) and complications was assessed using multivariable logistic regression analyses.

RESULTS

Median age (interquartile range [IQR] from 70-73 years), body mass index (IQR from 25 to 27 kg/m²) and preoperative glomerular filtration rate (IQR from 59 to 65 ml/min) were similar among all quartiles (all P > 0.05). Patients in Q4 had higher rates of previous abdominopelvic surgery (46.1% vs. 30.4%, P = 0.031) and American Society of Anesthesiologists score of 3 to 4 (72.3% vs. 47.1%, P = 0.003) compared to patients in Q1. Patients who underwent RARC in Q4 compared to Q1, had less estimated blood loss (250 ml vs. 350 ml, P < 0.001), shorter operative time (346 vs. 360 minutes, P < 0.001), and higher lymph node yield (22 vs. 17 nodes, P < 0.001). The 30-day and 90-day complication rates were 53% and 62%, respectively. Thirty-day complication rates were similar among all 4 quartiles (P > 0.05), but higher among patients in Q4 compared to Q1 within 90 days (74% vs. 54%, P = 0.01). On multivariable analysis, patients in Q4 were more likely to experience any 90-day complication (OR 2.03, 95%Cl 1.11-3.70) compared to Q1.

CONCLUSION

Our results show that with surgical experience, more complex cases can be performed while continuing to improve surgical quality. Nonetheless, there appears to be a trade-off between the increase in complexity of cases performed with experience and accepting higher rates of complications.

Survival Outcomes in Neoadjuvant Chemotherapy for High-grade Upper Tract Urothelial Carcinoma: A Nationally Representative Analysis

OBJECTIVE

To assess the impact of neoadjuvant chemotherapy (NAC) on survival outcomes in a contemporary cohort of patients with in upper tract urothelial carcinoma (UTUC).

METHODS

The National Cancer Database was queried from 2004 to 2015 to identify subjects who underwent nephroureterectomy for UTUC. Kaplan-Meier method with log-rank test was performed to compare all-cause mortality between patients who received preoperative chemotherapy to those who did not at each pathologic (p) TNM stage group: T1-4N0, N+, and M+ disease. Associations for all-cause mortality were identified using an adjusted Cox regression analysis.

RESULTS

A total of 10,315 chemoeligible subjects were included in the analysis. A total of 296 (2.9%) of patients received NAC prior to NU. Kaplan-Meier survival curves of the entire cohort demonstrated an overall survival advantage associated with administration of NAC (P = .017). Stratified by clinical staging, subjects with nonorgan-confined tumors had improved overall survival outcomes with NAC administration (P = .012). On multivariate analysis there was a statistically significant improvement in overall survival between in patients who received NAC. Of patients in the preoperative chemotherapy group who had clinically nonorgan-confined disease, 27.1% had organ-confined disease at time of surgery compared to 1.4% of those who underwent surgery as initial therapy.

CONCLUSION

In a contemporary cohort of subjects who underwent nephroureterectomy for UTUC, administration of NAC in patients with high-grade nonorgan-confined disease led to higher rates of pathologic downstaging and was associated with improved overall survival.

Impact of Body Mass Index on Outcomes Following Anatomic GreenLight Laser Photoselective Vaporization of the Prostate

Introduction: Obesity can lead to increased risk of perioperative complications in surgical patients, but evidence is lacking regarding the impact of obesity on bladder outlet surgery outcomes. We sought to assess the safety and efficacy of GreenLight photoselective vaporization of the prostate (PVP) in obese patients by comparing functional outcomes and complications in men, stratified according to the body mass index (BMI). Materials and Methods: A retrospective analysis was undertaken of 424 men who underwent 180W GreenLight PVP between 2012 and 2016 at two tertiary medical centers. Patients were stratified based on the World Health Organization (WHO) classification of obesity as determined by BMI. Normal weight men had BMI <25 kg/m², overweight men had BMI between 25 and 30 kg/m², and obese men had BMI greater than 30 kg/m². Primary endpoints examined were differences in intraoperative outcomes and incidence of intraoperative and postoperative complications between BMI groups. Secondary endpoints were improvements in the International Prostate Symptom Score, quality of life score, and the uroflowmetry variables, maximum urinary flow rate and postvoid residual. Results: The BMI groups did not differ regarding operative time or lasing time after matching for prostate volume, but overweight patients in the matched cohort still required higher mean energy use than normal weight men (258.6 kJ vs 233.9 kJ; p = 0.017). No significant differences between BMI groups were observed for intraoperative complications, postoperative complications, or readmission rates. All functional parameters were significantly improved at 24 months for each group, with no differences in improvement between groups. On multivariable analysis, BMI was not a significant predictor for outcomes following PVP. Conclusions: Increased BMI has a negligible effect on intraoperative parameters and does not affect postoperative complication rates or functional outcomes. GreenLight XPS 180W PVP is a safe and effective procedure in overweight and obese men.

Multicenter analysis of clinical and MRI characteristics associated with detecting clinically significant prostate cancer in PI-RADS (v2.0) category 3 lesions

OBJECTIVES

We sought to identify clinical and magnetic resonance imaging (MRI) characteristics in men with the Prostate Imaging - Reporting and Data System (PI-RADS) category 3 index lesions that predict clinically significant prostate cancer (CaP) on MRI targeted biopsy.

MATERIALS AND METHODS

Multicenter study of prospectively collected data for biopsy-naive men (n = 247) who underwent MRI-targeted and systematic biopsies for PI-RADS 3 index lesions. The primary endpoint was diagnosis of clinically significant CaP (Grade Group ≥2). Multivariable logistic regression models assessed for factors associated with clinically significant CaP. The probability distributions of clinically significant CaP based on different levels of predictors of multivariable models were plotted in a heatmap.

RESULTS

Men with clinically significant CaP had smaller prostate volume (39.20 vs. 55.10 ml, P < 0.001) and lower apparent diffusion coefficient (ADC) values (973 vs. 1068 μm²/s, P = 0.013), but higher prostate-specific antigen (PSA) density (0.21 vs. 0.13 ng/ml², P = 0.027). On multivariable analyses, lower prostate volume (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.92-0.97), lower ADC value (OR: 0.99, 95% CI: 0.99-1.00), and Prostate-specific antigen density >0.15 ng/ml² (OR: 3.51, 95% CI 1.61-7.68) were independently associated with significant CaP.

CONCLUSION

Higher PSA density, lower prostate volume and ADC values are associated with clinically significant CaP in biopsy-naïve men with PI-RADS 3 lesions. We present regression-derived probabilities of detecting clinically significant CaP based on various clinical and imaging values that can be used in decision-making. Our findings demonstrate an opportunity for MRI refinement or biomarker discovery to improve risk stratification for PI-RADS 3 lesions.

Temporal Changes in Demographic and Clinical Characteristics of Men With Prostate Cancer Electing for Conservative Management in the United States

OBJECTIVE

To characterize the role of clinical and sociodemographic factors in the use of conservative management for localized prostate cancer in the US between 2010 and 2015, and to understand how those factors evolved in light of the recent national increase in conservative management rates.

METHODS

Data from the Surveillance, Epidemiology, and End Results Program "Prostate with Watchful Waiting Database," where conservative treatment was delineated by a distinct classifier, was used to evaluate factors associated with electing for conservative management at initial diagnosis (2010-2015). Men aged ≥40 years with cT1-T2a and T2NOS with Gleason score 3 + 3 and 3 + 4 were included (n = 118,415). Multivariable logistic regression was used to determine the association between clinical and sociodemographic factors and electing conservative management.

RESULTS

Between 2010 and 15, a total of 22,099 (18.6%) men were managed conservatively. Mean age of men managed conservatively decreased from 66.6 to 64.6 years, and median prostate-specific antigen (PSA) increased from 5.7 to 6.0 ng/mL, P <.0001. Men with lower income experienced a greater increase in conservative management rates compared to those with high income (152% vs 72% for third and fifth [richest] income quintiles, respectively). On multivariable analysis, Gleason score 3 + 3, older age, lower PSA, more recent year, treatment in the West, and higher levels of county income were significantly associated with conservative management.

CONCLUSION

Characteristics of men undergoing conservative management are rapidly changing. Younger men, men with higher PSAs, and men of all incomes are increasingly being managed conservatively. Narrowing of income-based disparities with concurrent broadening of patients considered eligible for surveillance is encouraging.

Prostate Multiparametric Magnetic Resonance Imaging Features Following Partial Gland Cryoablation

OBJECTIVE

To assess the qualitative and quantitative changes on prostate multiparametric magnetic resonance imaging (mpMRI) following partial gland ablation (PGA) with cryotherapy and correlate with histopathology.

METHODS

We used 3D Slicer to generate prostate models and segment ipsilateral (treated) and contralateral peripheral and transition zones in 10 men who underwent MRI/transrectal ultrasound fusion-guided PGA during 2017-2018. Pre- and post-PGA volumes of prostate segments were compared. Post-PGA mpMRI were categorized according to PI-RADS v2 and treatment response on mpMRI was assessed in a manner similar to the radiology evaluation framework following liver lesion ablation.

RESULTS

Median volume of ipsilateral peripheral and transition zones decreased from 10.9 mL and 13.0 mL to 7.2 mL and 10.8 mL (P = .005), respectively. Median volume of contralateral peripheral and transition zones also decreased from 12.1 mL and 12.5 mL to 9.9 mL to 10.4 mL (P = .005), respectively. Five men had clinically significant disease (Grade group ≥2) on post-PGA biopsy (3 within treatment field and 2 outside). Of the men with clinically significant prostate cancer, mpMRI revealed PI-RADS 3 lesions in 2. However, the treatment response framework did not detect residual disease.

CONCLUSION

PGA results in asymmetrical and significant reductions in prostate volume. Our results highlight the need for a separate assessment framework to enable standardization of the interpretation and reporting of post-PGA surveillance mpMRI. Moreover, our findings have significant implications for MRI-targeted surveillance biopsy following PGA with cryotherapy.

Validation of risk factors for recurrence of renal cell carcinoma: Results from a large single-institution series

Purpose

To validate prognostic factors and determine the impact of obesity, hypertension, smoking and diabetes mellitus (DM) on risk of recurrence after surgery in patients with localized renal cell carcinoma (RCC).

Materials and methods

We performed a retrospective cohort study among patients that underwent partial or radical nephrectomy at Weill Cornell Medicine for RCC and collected preoperative information on RCC risk factors, as well as pathological data. Cases were reviewed for radiographic evidence of RCC recurrence. A Cox proportional-hazards model was developed to determine the contribution of RCC risk factors to recurrence risk. Disease-free survival and overall survival were analyzed using the Kaplan-Meier method and log-rank test.

Results

We identified 873 patients who underwent surgery for RCC between the years 2000–2015. In total 115 patients (13.2%) experienced a disease recurrence after a median follow up of 4.9 years. In multivariate analysis, increasing pathological T-stage (HR 1.429, 95% CI 1.265–1.614) and Nuclear grade (HR 2.376, 95% CI 1.734–3.255) were independently associated with RCC recurrence. In patients with T1-2 tumors, DM was identified as an additional independent risk factor for RCC recurrence (HR 2.744, 95% CI 1.343–5.605). Patients with DM had a significantly shorter median disease-free survival (1.5 years versus 2.6 years, p = 0.004), as well as median overall survival (4.1 years, versus 5.8 years, p<0.001).

Conclusions

We validated high pathological T-stage and nuclear grade as independent risk factors for RCC recurrence following nephrectomy. DM is associated with an increased risk of recurrence among patients with early stage disease.

IDEAL Stage 2a experience with in-office, transperineal MRI/ultrasound software fusion targeted prostate biopsy

Objective

Although the feasibility of transperineal biopsy under local anesthesia has been demonstrated, little is known regarding the application of MRI/ultrasound software fusion targeted biopsy for transperineal biopsy under local anesthesia. The objective of our study is to describe our initial experience with in-office transperineal MRI/ultrasound software fusion targeted biopsy (Idea, Development, Exploration, Assessment, Long-term Follow-up [IDEAL] Stage 2a).

Methods

Between October 2017 and July 2019, 33 men underwent in-office transperineal MRI-targeted biopsy using the Artemis (Eigen, Grass Valley, CA, USA) fixed-robotic arm system. The indication for biopsy was elevated prostate specific antigen (PSA) (n=14), prior negative biopsy (n=10), active surveillance (n=6), and surveillance after partial gland cryoablation (n=3). We prospectively captured patient demographic and clinical characteristics, biopsy outcomes, and complications. Complications were classified according to Common Terminology Criteria for Adverse Events (CTCAE) V.5.0.

Results

The median patient age was 67 years (IQR 61–71) and the median serum PSA level was 7.0 ng/mL (IQR 5.1–11.4). The median duration of in-office MRI-targeted transperineal biopsy was 26 min (IQR 23–28). Overall, transperineal MRI-targeted biopsy detected prostate cancer in 18 (54.6%) men, with 8 (24.2%) being clinically significant (Gleason Score ≥3+4, Grade Group ≥2). Clinically significant prostate cancer was detected in four (28.6%) biopsy naïve men, two (20.0%) men with a prior negative, one (16.7%) man on active surveillance and one (33.3%) man following partial gland ablation. Three (9.1%) men experienced complications: two hematuria and one urinary retention.

Conclusion

Our findings demonstrate the feasibility of the fixed-robotic arm fusion platform for in-office transperineal MRI-targeted biopsy and a low rate of adverse events. However, larger prostate size precludes MRI/ultrasound software fusion and pubic arch interference hindered the transperineal MRI-targeted approach in 9.1% of men. Pubic arch interference was overcome by a free-hand approach with software fusion guidance.

Concordance Between Biopsy and Radical Prostatectomy Pathology in the Era of Targeted Biopsy: A Systematic Review and Meta-analysis

CONTEXT

Multiparametric magnetic resonance imaging (mpMRI)-targeted transrectal prostate biopsy (TBx) may better predict pathology at radical prostatectomy than systematic transrectal prostate biopsy (SBx).

OBJECTIVE

To assess concordance between biopsy and radical prostatectomy pathology in men undergoing a TBx as compared with those undergoing an SBx.

EVIDENCE ACQUISITION

Four electronic databases (Ovid MEDLINE, Ovid EMBASE, the Cochrane Library [Wiley], and EBSCHOHost) were searched from inception until July 2018. Studies were included if they were published after 2012, conducted both SBx and TBx, and compared the biopsy results with final pathology after radical prostatectomy for ≥50 patients. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized. Bias was appraised using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool.

EVIDENCE SYNTHESIS

Our search yielded 10 studies including 1215 men. However, our inclusion criteria applied only to a proportion of men included in these studies. The median age was 65 yr and the median prostate-specific antigen level was 7.2 ng/ml. In the eight studies examining upgrading at prostatectomy, pathology from SBx was significantly more likely to be upgraded relative to TBx (odds ratio [OR] 2.47, 95% confidence interval [CI] 1.48-4.14, p =  0.001). We found no significant difference in downgrading (OR 1.13, 95% CI 0.48-2.67, p =  0.783) between TBx and SBx. For both biopsy-naïve men and men with a prior negative biopsy, results from SBx were more likely to be upgraded than TBx at prostatectomy (OR 1.6 [95% CI 1.02-2.27, p <  0.001] and OR 4.23 [95% CI 1.68-8.48, p =  0.003], respectively).

CONCLUSIONS

Pathologic upgrading at prostatectomy was less likely with mpMRI-targeted biopsy versus systematic biopsy alone, without concurrent increase in downgrading. This increased accuracy should improve confidence in management decisions based on MRI-targeted biopsy pathology.

PATIENT SUMMARY

We reviewed the ability of multiparametric magnetic resonance imaging -targeted biopsy to predict cancer grade at radical prostatectomy. We found that targeted biopsy provides more accurate assessment of Gleason score at prostatectomy than systematic biopsy.

Race and prostate imaging: implications for targeted biopsy and image-based prostate cancer interventions

Purpose

For men with an elevated prostate-specific antigen (PSA), there is a strong evidence for prostate MRI to assess the risk of clinically significant prostate cancer (CSPC) and guide targeted-biopsy interventions. Prostate MRI is assessed using the Prostate Imaging-Reporting and Data System (PI-RADS), which is scored from 1 to 5. Equivocal or suspicious findings (PI-RADS 3–5) are recommended for subsequent targeted biopsy, for which the risk of infection and sepsis is increasing. However, PI-RADS was developed primarily in men of European descent. We sought to elucidate PI-RADS and MRI-targeted biopsy outcomes in Asian men, a rapidly growing population in the USA, Europe, Australia and internationally.

Materials and methods

A prospective cohort of 544 men with elevated PSA without a diagnosis of prostate cancer who underwent MRI-targeted biopsy at our institution from January 2012 to December 2018 was analyzed. We categorized the cohort by self-designated race then used a validated algorithm which uses surname lists to identify a total of 78 (14%) Asian-Americans. The primary outcome was the likelihood of diagnosing CSPC (Gleason grade group >1) in Asian-Americans versus non-Asian-Americans. Multivariable logistic regression was used to determine the association of demographic and other characteristics with CSPC.

Results

Overall, MRI-targeted biopsy identified CSPC in 17% of Asian-American men versus 39% of non-Asian-American men (p<0.001). Notably for PI-RADS 3, only 6% of Asian-Americans versus 15% of others were diagnosed with CSPC. In adjusted analyses, Asian-American men were less likely to be diagnosed on MRI-targeted biopsy with CSPC (OR 0.30, 95% CI 0.14 to 0.65, p=0.002) and indolent prostate cancer (OR 0.37, 95% CI 0.15 to 0.91, p=0.030) than other races. Regardless of race those who were biopsy naïve were more likely (OR 2.25, 95% CI 1.45 to 3.49, p<0.001) to be diagnosed with CSPC.

Conclusion

We found that PI-RADS underperforms in Asian-American men. For instance, only 2 of 35 (6%) Asian-American men with PI-RADS 3 were diagnosed with CSPC on MRI targeted biopsy. This has significant implications for overuse of diagnostic and image-guided interventional approaches in Asian-Americans, given the increasing risk of infectious complications from biopsy. Additional validation studies are needed to confirm our findings.

Urinary pH and the risk of recurrence in patients with non-muscle invasive bladder cancer

INTRODUCTION

To evaluate the effect of urine pH on tumor recurrence rates in patients undergoing surveillance after initial diagnosis of non-muscle invasive bladder cancer (NMIBC).

MATERIALS AND METHODS

All patients diagnosed with NMIBC at a tertiary referral center from January 2004 to March 2015 were reviewed. Our primary outcome was time to first recurrence after transurethral resection of bladder tumor (TURBT). Patients were analyzed according to the average urine pH of all urinalysis data over the surveillance period from TURBT to first recurrence. Kaplan-Meier survival analysis was used to determine differences in median time to recurrence. Cox proportional hazards regression was used to assess independent predictors of cancer recurrence.

RESULTS

A total of 252 patients were included, of which 155 patients had average pH ≤ 6 (median pH 5.5) and 97 patients had average pH > 6 (median pH 6.8), p < 0.001. There was no significant difference in median time to recurrence between low/acidic pH (≤ 6) and high/basic pH (> 6) groups (28 months versus 17 months, respectively, p = 0.3444). Similarly, urine pH did not affect the risk of recurrence in a subgroup analysis stratified by smoking status. On multivariable Cox regression analysis, there was no association between average pH and recurrence among high grade tumors (HR = 1.33, 95% CI = 0.76 to 2.34, p = 0.3186), or low grade tumors (HR = 1.013, 95% CI = 1.01 to 1.58, p = 0.96).

CONCLUSIONS

There was no association between urine pH and risk of tumor recurrence, regardless of smoking status. These findings suggest that modification of urine pH is unlikely to decrease the frequency of tumor recurrence in patients with NMIBC.

Racial Variation in the Utility of Urinary Biomarkers PCA3 and T2ERG in a Large Multicenter Study

PURPOSE

To our knowledge it is unknown whether urinary biomarkers for prostate cancer have added utility to clinical risk calculators in different racial groups. We examined the utility of urinary biomarkers added to clinical risk calculators for predicting prostate cancer in African American and nonAfrican American men.

MATERIALS AND METHODS

Demographics, PCPT (Prostate Cancer Prevention Trial) risk scores, data on the biomarkers data PCA3 (prostate cancer antigen 3) and T2ERG (transmembrane protease serine 2 and v-ets erythroblastosis virus E26 oncogene homolog gene fusion), and biopsy pathology features were prospectively collected on 718 men as part of EDRN (Early Detection Research Network). Utility was determined by generating ROC curves and comparing AUC values for the baseline multivariable PCPT model and for models containing biomarker scores.

RESULTS

PCA3 and T2ERG added utility for the prediction of prostate cancer and clinically significant prostate cancer when combined with the PCPT Risk Calculator. This utility was seen in nonAfrican American men only for PCA3 (AUC 0.64 increased to 0.75 for prostate cancer and to 0.69-0.77 for clinically significant prostate cancer, both p <0.001) and for T2ERG (AUC 0.64-0.74 for prostate cancer, p <0.001, and 0.69-0.73 for clinically significant prostate cancer, p = 0.029). African American men did not have an added benefit with the addition of biomarkers, including PCA3 (AUC 0.75-0.77, p = 0.64, and 0.65-0.66, p = 0.74) and T2ERG (AUC 0.75-0.74, p = 0.74, and 0.65-0.64, p = 0.88), for prostate cancer and clinically significant prostate cancer, respectively. Limitations include the small number of African American men (72). The post hoc subgroup analysis nature of the study limited findings to being hypothesis generating.

CONCLUSIONS

As novel biomarkers are discovered, clinical utility should be established across demographically diverse cohorts.