1
|
Tan HJ, Spratte BN, Deal AM, Heiling HM, Nazzal EM, Meeks W, Fang R, Teal R, Maihan BV, Bennett AV, Blalock S, Chung A, Gotz D, Nielsen M, Reuland DS, Harris AH, Basch E. Clinical Decision Support for Surgery: A Mixed Methods Study on Design and Implementation Perspectives from Urologists. Urology 2024:S0090-4295(24)00307-8. [PMID: 38697362 DOI: 10.1016/j.urology.2024.04.033] [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: 01/25/2024] [Revised: 04/08/2024] [Accepted: 04/20/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVES To assess urologist attitudes toward clinical decision support embedded into the electronic health record and define design needs to facilitate implementation and impact. With recent advances in big data and artificial intelligence, enthusiasm for personalized, data-driven tools to improve surgical decision-making has grown, but the impact of current tools remains limited. METHODS A sequential explanatory mixed methods study from 2019-2020 was performed. First, survey responses from the 2019 American Urological Association annual census evaluated attitudes toward an automatic clinical decision support tool that would display risk/benefit data. This was followed by the purposeful sampling of 25 urologists and qualitative interviews assessing perspectives on clinical decision support impact and design needs. Bivariable, multivariable, and coding-based thematic analysis were applied and integrated. RESULTS Among a weighted sample of 12,366 practicing urologists, the majority agreed clinical decision support would help decision-making (70.9%, 95% CI 68.7-73.2%), aid patient counseling (78.5%, 95% CI 76.5-80.5%), save time (58.1%, 95% CI 55.7-60.5%), and improve patient outcomes (42.9%, 95% CI 40.5-45.4%). More years in practice was negatively associated with agreement (p<0.001). Urologists described how clinical decision support could bolster evidence-based care, personalized medicine, resource utilization, and patient experience. They also identified multiple implementation barriers and provided suggestions on form, functionality, and visual design to improve usefulness and ease of use. CONCLUSIONS Urologists have favorable attitudes toward the potential for clinical decision support in the electronic health record. Smart design will be critical to ensure effective implementation and impact.
Collapse
Affiliation(s)
- Hung-Jui Tan
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC.
| | - Brooke N Spratte
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC.
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC.
| | - Hillary M Heiling
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC.
| | - Elizabeth M Nazzal
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC.
| | - William Meeks
- American Urological Association Data Management and Statistical Services.
| | - Raymond Fang
- American Urological Association Data Management and Statistical Services.
| | - Randall Teal
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Connected Health Applications and Interventions Core, University of North Carolina, Chapel Hill, NC.
| | - B Vu Maihan
- Connected Health Applications and Interventions Core, University of North Carolina, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC.
| | - Antonia V Bennett
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC.
| | - Susan Blalock
- Pharmaceutical Outcomes & Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC.
| | - Arlene Chung
- Department of Bioinformatics, Duke University, Durham, NC.
| | - David Gotz
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; School of Information and Library Science, University of North Carolina, Chapel Hill, NC.
| | - Matthew Nielsen
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC.
| | - Daniel S Reuland
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC.
| | - Alex Hs Harris
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, CA.
| | - Ethan Basch
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC; Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC.
| |
Collapse
|
2
|
Weiss K, Abimbola O, Mueller D, Basak R, Basch E, Parisse T, Hamad J, Nielsen M, Tan HJ, Wallen E, Bjurlin M, Smith AB. Feasibility, Acceptability, and Outcomes of a Mobile Health Tool for Radical Cystectomy Recovery. J Urol 2024; 211:266-275. [PMID: 37972245 DOI: 10.1097/ju.0000000000003787] [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] [Received: 08/04/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE Postoperative education and symptom tracking are essential following cystectomy to reduce readmission rates and information overload. To address these issues, an internet-based tool was developed to provide education, alerts, and symptom tracking. We aimed to evaluate the tool's feasibility, acceptability, and impact on complication and readmission rates. MATERIALS AND METHODS Thirty-three eligible patients over 18 years old scheduled for cystectomy were enrolled. Patients were asked to use the mobile health (mHealth) tool daily for the first 2 weeks, then less frequently up to 90 days after discharge. Descriptive statistics were used to summarize study variables. Feasibility was defined as at least 50% of patients using the tool once a week, and acceptability as patient satisfaction of > 75%. RESULTS Use of the mHealth tool was feasible, with 90% of patients using it 1 week after discharge, but engagement declined over time to 50%, with technological difficulties being the main reason for nonengagement. Patient and provider acceptability was high, with satisfaction > 90%. Within 90 days, 36% experienced complications after discharge and 30% were readmitted. Engagement with the mHealth application varied but was not statistically associated with readmission (P = .21). CONCLUSIONS The study showed that the electronic mobile health intervention for patients undergoing cystectomy was feasible, acceptable, and provided valuable educational content and symptom management. Future larger studies are needed to determine the tool's effectiveness in improving patient outcomes and its potential implementation into routine clinical care.
Collapse
Affiliation(s)
- Kristin Weiss
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Obafunbi Abimbola
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Dana Mueller
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ramsankar Basak
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ethan Basch
- Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
- Department of Medicine, Division of Hematology and Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Taylor Parisse
- Department of Emergency Medicine, University of Pittsburgh Medical Center at Harrisburg, Harrisburg, Pennsylvania
| | - Judy Hamad
- Department of Dermatology, Henry Ford Health, Detroit, Michigan
| | - Matthew Nielsen
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Hung-Jui Tan
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Eric Wallen
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Marc Bjurlin
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Angela B Smith
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| |
Collapse
|
3
|
Ippolito GM, Reines K, Meeks WD, Mbassa R, Ellimoottil C, Faris A, Reuland DS, Nielsen ME, Teal R, Vu M, Clemens JQ, Tan HJ. Perceived vs Actual Shared Decision-Making Behavior Among Urologists: A Convergent, Parallel, Mixed-Methods Study of Self-Reported Practice. Urology 2024; 183:78-84. [PMID: 37996015 DOI: 10.1016/j.urology.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/30/2023] [Accepted: 10/31/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE To evaluate the association between self-perceived use of shared decision-making among urologists with use of validated prediction tools and self-described surgical decision-making. METHODS This is a convergent mixed methods study of these parallel data from two modules (Shared Decision Making and Validated Prediction tools) within the 2019 American Urological Association (AUA) Annual Census. The shared decision-making (SDM) module queried aspects of SDM that urologists regularly used. The validated prediction tools module queried whether urologists regularly used, trusted, and found prediction tools helpful. Selected respondents to the 2019 AUA Annual Census underwent qualitative interviews on their surgical decision-making. RESULTS In the weight sampled of 12,312 practicing urologists, most (77%) reported routine use of SDM, whereas only 30% noted regular use of validated prediction tools. On multivariable analysis, users of prediction tools were not associated with regular SDM use (31% vs 28%, P = .006) though was associated with use of decision aids f (32% vs 26%, P < .001). Shared decision-making emerged thematically with respect to matching treatment options, prioritizing goals, and navigating challenging decisions. However, the six specific components of shared decision-making ranged in their mentions within qualitative interviews. CONCLUSION Most urologists report performing SDM as supported by its thematic presence in surgical decision-making. However, only a minority use validated prediction tools and urologists infrequently mention specific SDM components. This discrepancy provides an opportunity to explore how urologists perform SDM and can be used to support integrated strategies to implement SDM more effectively in clinical practice.
Collapse
Affiliation(s)
- Giulia M Ippolito
- Department of Urology, University of Michigan, Ann Arbor, MI; Ann Arbor VA Medical Center, Ann Arbor, MI.
| | - Katy Reines
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - William D Meeks
- American Urological Association (AUA), Data Management and Statistical Analysis, Linthicum, MD; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Rachel Mbassa
- American Urological Association (AUA), Data Management and Statistical Analysis, Linthicum, MD; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Chad Ellimoottil
- Department of Urology, University of Michigan, Ann Arbor, MI; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Anna Faris
- Department of Urology, University of Michigan, Ann Arbor, MI; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Daniel S Reuland
- Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Matthew E Nielsen
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Randall Teal
- Lineberger Comprehensive Cancer Center, Connected Health Applications and Interventions (CHAI) Core, University of North Carolina, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Maihan Vu
- Lineberger Comprehensive Cancer Center, Connected Health Applications and Interventions (CHAI) Core, University of North Carolina, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - J Quentin Clemens
- Department of Urology, University of Michigan, Ann Arbor, MI; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Hung-Jui Tan
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| |
Collapse
|
4
|
Bethel EC, Matthew-Onabanjo AN, Kay HE, Basak R, Demzik A, Filippou P, Viprakasit D, Borawski KM, Wallen EM, Smith AB, Tan HJ. Linguistic Differences Based on Gender and Race in Urology Application Personal Statements: A Comparison of 2017 and 2023 Applications. Urol Clin North Am 2023; 50:531-539. [PMID: 37775212 DOI: 10.1016/j.ucl.2023.06.013] [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: 10/01/2023]
Abstract
While diversity and inclusion efforts have increased in urology, comparative analysis of personal statements from 2016-2017 and 2022-2023 residency applications showed few linguistic changes over time by gender or race/ethnicity. These results suggest the need for directed efforts to engage, mentor, and coach females and underrepresented minorities during medical school and the urology application process.
Collapse
Affiliation(s)
- Emma C Bethel
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Asia N Matthew-Onabanjo
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Hannah E Kay
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Ram Basak
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Alysen Demzik
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Pauline Filippou
- Department of Urology, Kaiser Permanente Northern California, Santa Clara Medical Center, Santa Clara, CA, USA
| | - Davis Viprakasit
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Kristy M Borawski
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Eric M Wallen
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Angela B Smith
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Hung-Jui Tan
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.
| |
Collapse
|
5
|
Zambrano IA, Hwang S, Basak R, Spratte BN, Filson CP, Jacobs BL, Tan HJ. Patterns of multispecialty care for low- and intermediate-risk prostate cancer in the use of active surveillance. Urol Oncol 2023; 41:388.e1-388.e8. [PMID: 37286404 DOI: 10.1016/j.urolonc.2023.04.024] [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] [Received: 01/09/2023] [Revised: 03/20/2023] [Accepted: 04/24/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Multidisciplinary models of care have been advocated for prostate cancer (PC) to promote shared decision-making and facilitate quality care. Yet, how this model applies to low-risk disease where the preferred management is expectant remains unclear. Accordingly, we examined recent practice patterns in specialty visits for low/intermediate-risk PC and resultant use of active surveillance (AS). METHODS Using SEER-Medicare, we ascertained whether patients saw urology and radiation oncology (i.e., multispecialty care) versus urology alone, based on self-designated specialty codes, for newly diagnosed PC from 2010 to 2017. We also examined the association with AS, defined as the absence of treatment within 12 months of diagnosis. Time trends were analyzed using Cochran-Armitage test. Chi-squared and logistic regression analyses were applied to compare sociodemographic and clinicopathologic characteristics between these models of care. RESULTS The proportion of patients seeing both specialists was 35.5% and 46.5% for low- and intermediate-risk patients respectively. Trend analysis showed a decline in multispecialty care in low-risk patients (44.1% to 25.3% years 2010-2017; P < 0.001). Between 2010 and 2017, the use of AS increased 40.9% to 68.6% (P < 0.001) and 13.1% to 24.6% (P < 0.001) for patients seeing urology and those seeing both specialists respectively. Age, urban residence, higher education, SEER region, co-morbidities, frailty, Gleason score, predicted receipt of multispecialty care (all P < 0.02). CONCLUSIONS Uptake of AS among men with low-risk PC has occurred primarily under the purview of urologists. While selection is certainly at play, these data suggest that multispecialty care may not be required to promote the utilization of AS for men with low-risk PC.
Collapse
Affiliation(s)
- Ibardo A Zambrano
- Department of Urology, University of North Carolina, Chapel Hill, NC.
| | - Soohyun Hwang
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Ram Basak
- Department of Urology, University of North Carolina, Chapel Hill, NC
| | | | | | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Hung-Jui Tan
- Department of Urology, University of North Carolina, Chapel Hill, NC
| |
Collapse
|
6
|
Lim KY, Khoo CS, Rajah R, Tan HJ, Tajurudin FW. Efficacy and safety of adjunctive treatment with perampanel in epilepsy patients. Med J Malaysia 2023; 78:635-638. [PMID: 37775491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
INTRODUCTION Epilepsy is a neurological disease with high global prevalence. Almost one-third of epilepsy patients continue having seizures despite adequate treatment. Perampanel has been widely used in the Western countries as an adjunctive therapy for both generalized and focal seizures. Owing to its high cost, the use of perampanel is limited in our country. MATERIALS AND METHODS We conducted a descriptive, retrospective study among epilepsy patients treated with perampanel. We aimed to assess the efficacy and safety of perampanel as an adjunctive in our hospital. RESULTS AND CONCLUSIONS From our cohort of 25 patients, most of the patients were either on one or three anti-seizure medications (ASMs) prior to initiation of perampanel. Perampanel was added in 88% of them due to persistent seizures. Twenty-two (88%) patients experienced reduction in seizure frequency. 12% experienced mild side effects, which were leg cramps, hyponatremia and drowsiness. Only 1 patient stopped perampanel due to its side effects. CONCLUSION Perampanel is a well-tolerated ASM that should be widely used as an adjunctive. More studies with regards to its efficacy and safety involving more centres are encouraged in Malaysia.
Collapse
Affiliation(s)
- K Y Lim
- Hospital Canselor Tuanku Muhriz, Department of Medicine, Malaysia.
| | - C S Khoo
- Hospital Canselor Tuanku Muhriz, Department of Medicine, Malaysia
| | - R Rajah
- Hospital Canselor Tuanku Muhriz, Department of Medicine, Malaysia
| | - H J Tan
- Hospital Canselor Tuanku Muhriz, Department of Medicine, Malaysia
| | - F W Tajurudin
- Hospital Canselor Tuanku Muhriz, Department of Pharmacy, Malaysia
| |
Collapse
|
7
|
Schee JP, Ang CL, Crystal Teoh SC, Tan HJ, Chew SH, Steven A, Hii DW, Chin YT, Loh EW, Samuel D, Narayanan P, Husin M, Linda Then YY, Cheah CF, Cheah WK, Isa ZC, Ibrahim A, Chia YK, Ibrahim KA, Looi I, Law WC, Abdul Aziz Z. Intravenous thrombolysis for multi-ethnic Asians with acute ischaemia stroke in Malaysian public primary stroke centres versus acute stroke ready hospitals: Comparison of real-world clinical outcomes. Med J Malaysia 2023; 78:594-601. [PMID: 37775485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
INTRODUCTION Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator is beneficial in acute ischaemic stroke (AIS). We aim to compare the realworld clinical outcomes and service efficiency of IVT in Malaysian primary stroke centres (PSCs) versus acute stroke ready hospitals (ASRHs). MATERIALS AND METHODS We conducted a multi-centre cohort study involving 5 PSCs and 7 ASRHs in Malaysia. Through review of medical records of AIS patients who received IVT from 01 January 2014 to 30 June 2021, real-world data was extracted for analysis. Univariate and multivariate regression models were employed to evaluate the role of PSCs versus ASRHs in post-IVT outcomes and complications. Statistical significance was set at p<0.05. RESULTS A total of 313 multi-ethnic Asians, namely 231 from PSCs and 82 from ASRHs, were included. Both groups were comparable in baseline demographic, clinical, and stroke characteristics. The efficiency of IVT delivery (door-toneedle time), functional outcomes (mRS at 3 months post- IVT), and rates of adverse events (intracranial haemorrhages and mortality) following IVT were comparable between the 2 groups. Notably, 46.8% and 48.8% of patients in PSCs and ASRHs group respectively (p=0.752) achieved favourable functional outcome (mRS≤1 at 3 months post-IVT). Regression analyses demonstrated that post-IVT functional outcomes and adverse events were independent of the role of PSCs or ASRHs. CONCLUSION Our study provides real-world evidence which suggests that IVT can be equally safe, effective, and efficiently delivered in ASRHs. This may encourage the establishment of more ASRHs to extend the benefits of IVT to a greater proportion of stroke populations and enhance the regional stroke care.
Collapse
Affiliation(s)
- J P Schee
- Tawau Hospital, Department of Medicine, Sabah, Malaysia
| | - C L Ang
- Tawau Hospital, Department of Medicine, Sabah, Malaysia
| | - S C Crystal Teoh
- Sarawak General Hospital, Department of Medicine, Sarawak, Malaysia.
| | - H J Tan
- Raja Permaisuri Bainun Hospital, Department of Medicine, Perak, Malaysia
| | - S H Chew
- Queen Elizabeth Hospital, Department of Medicine, Sabah, Malaysia
| | - A Steven
- Sarawak General Hospital, Department of Medicine, Sarawak, Malaysia
| | - D W Hii
- Sarawak General Hospital, Department of Medicine, Sarawak, Malaysia
| | - Y T Chin
- Sultanah Nur Zahirah Hospital, Department of Medicine, Terengganu, Malaysia,
| | - E W Loh
- Bintulu Hospital, Department of Medicine, Sarawak, Malaysia
| | - D Samuel
- Bintulu Hospital, Department of Medicine, Sarawak, Malaysia
| | - P Narayanan
- Sarikei Hospital, Department of Medicine, Sarawak, Malaysia
| | - M Husin
- Sultanah Nur Zahirah Hospital, Department of Medicine, Terengganu, Malaysia
| | - Y Y Linda Then
- Sarawak General Hospital, Department of Medicine, Sarawak, Malaysia
| | - C F Cheah
- Raja Permaisuri Bainun Hospital, Department of Medicine, Perak, Malaysia
| | - W K Cheah
- Raja Permaisuri Bainun Hospital, Department of Medicine, Perak, Malaysia
| | - Z C Isa
- Sultan Abdul Halim Hospital, Department of Medicine, Kedah, Malaysia
| | - A Ibrahim
- Sultan Abdul Halim Hospital, Department of Medicine, Kedah, Malaysia
| | - Y K Chia
- Queen Elizabeth Hospital, Department of Medicine, Sabah, Malaysia
| | - K A Ibrahim
- Sultan Abdul Halim Hospital, Department of Medicine, Kedah, Malaysia
| | - I Looi
- Seberang Jaya Hospital, Department of Medicine, Penang, Malaysia
| | - W C Law
- Sarawak General Hospital, Department of Medicine, Sarawak, Malaysia
| | - Z Abdul Aziz
- Sultanah Nur Zahirah Hospital, Department of Medicine, Terengganu, Malaysia
| |
Collapse
|
8
|
Lazard AJ, Nicolla S, Vereen RN, Pendleton S, Charlot M, Tan HJ, DiFranzo D, Pulido M, Dasgupta N. Exposure and Reactions to Cancer Treatment Misinformation and Advice: Survey Study. JMIR Cancer 2023; 9:e43749. [PMID: 37505790 PMCID: PMC10422174 DOI: 10.2196/43749] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 04/28/2023] [Accepted: 05/23/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Cancer treatment misinformation, or false claims about alternative cures, often spreads faster and farther than true information on social media. Cancer treatment misinformation can harm the psychosocial and physical health of individuals with cancer and their cancer care networks by causing distress and encouraging people to abandon support, potentially leading to deviations from evidence-based care. There is a pressing need to understand how cancer treatment misinformation is shared and uncover ways to reduce misinformation. OBJECTIVE We aimed to better understand exposure and reactions to cancer treatment misinformation, including the willingness of study participants to prosocially intervene and their intentions to share Instagram posts with cancer treatment misinformation. METHODS We conducted a survey on cancer treatment misinformation among US adults in December 2021. Participants reported their exposure and reactions to cancer treatment misinformation generally (saw or heard, source, type of advice, and curiosity) and specifically on social media (platform, believability). Participants were then randomly assigned to view 1 of 3 cancer treatment misinformation posts or an information post and asked to report their willingness to prosocially intervene and their intentions to share. RESULTS Among US adult participants (N=603; mean age 46, SD 18.83 years), including those with cancer and cancer caregivers, almost 1 in 4 (142/603, 23.5%) received advice about alternative ways to treat or cure cancer. Advice was primarily shared through family (39.4%) and friends (37.3%) for digestive (30.3%) and natural (14.1%) alternative cancer treatments, which generated curiosity among most recipients (106/142, 74.6%). More than half of participants (337/603, 55.9%) saw any cancer treatment misinformation on social media, with significantly higher exposure for those with cancer (53/109, 70.6%) than for those without cancer (89/494, 52.6%; P<.001). Participants saw cancer misinformation on Facebook (39.8%), YouTube (27%), Instagram (22.1%), and TikTok (14.1%), among other platforms. Participants (429/603, 71.1%) thought cancer treatment misinformation was true, at least sometimes, on social media. More than half (357/603, 59.2%) were likely to share any cancer misinformation posts shown. Many participants (412/603, 68.3%) were willing to prosocially intervene for any cancer misinformation posts, including flagging the cancer treatment misinformation posts as false (49.7%-51.4%) or reporting them to the platform (48.1%-51.4%). Among the participants, individuals with cancer and those who identified as Black or Hispanic reported greater willingness to intervene to reduce cancer misinformation but also higher intentions to share misinformation. CONCLUSIONS Cancer treatment misinformation reaches US adults through social media, including on widely used platforms for support. Many believe that social media posts about alternative cancer treatment are true at least some of the time. The willingness of US adults, including those with cancer and members of susceptible populations, to prosocially intervene could initiate the necessary community action to reduce cancer treatment misinformation if coupled with strategies to help individuals discern false claims.
Collapse
Affiliation(s)
- Allison J Lazard
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sydney Nicolla
- Hussman School of Journalism and Media, University of North Carolina at Chapel Hll, Chapel Hill, NC, United States
| | - Rhyan N Vereen
- Hussman School of Journalism and Media, University of North Carolina at Chapel Hll, Chapel Hill, NC, United States
| | - Shanetta Pendleton
- Hussman School of Journalism and Media, University of North Carolina at Chapel Hll, Chapel Hill, NC, United States
| | - Marjory Charlot
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Medicine, Division of Oncology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Hung-Jui Tan
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Urology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Dominic DiFranzo
- P.C. Rossin College of Engineering and Applied Science, Lehigh University, Bethlehem, PA, United States
| | - Marlyn Pulido
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Nabarun Dasgupta
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| |
Collapse
|
9
|
Spratte BN, Tan HJ, Zambrano IA, Basak RS, Filson CP, Jacobs BL, Hwang S. Use of expectant management based on prostate cancer risk and health status: How far are we from a risk-adapted approach? Urol Oncol 2023; 41:323.e17-323.e25. [PMID: 37149430 DOI: 10.1016/j.urolonc.2023.04.006] [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] [Received: 09/02/2022] [Revised: 03/21/2023] [Accepted: 04/01/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVES While active surveillance, a form of expectant management (EM), is preferred for patients with low-risk prostate cancer (PCa), some favor a more risk-adapted approach that recognizes patient preferences and condition-specific factors. However, previous research has shown non-patient-related factors often drive PCa treatment. In this context, we characterized trends in AS with respect to disease risk and health status. METHODS AND MATERIALS Using SEER-Medicare data, we identified men 66 years and older diagnosed with localized low- and intermediate-risk PCa from 2008 to 2017 and examined receipt of EM, defined as the absence of treatment (i.e., surgery, cryotherapy, radiation, chemotherapy, and androgen deprivation therapies) within 1 year of diagnosis. We performed bivariable analysis to compare trends in use for EM vs. treatment, stratified by disease risk (i.e., Gleason 3+3, 3+4, 4+3; PSA<10, 10-20) and health status (i.e., NCI Comorbidity Index (NCI), frailty, life expectancy). We then ran a multivariable logistic regression model to examine determinants of EM. RESULTS Within this cohort, 26,364 (38%) were categorized as low-risk (i.e., Gleason 3+3 and PSA<10) and 43,520 (62%) as intermediate-risk (i.e., all others). Over the study period, use of EM significantly increased across all risk groups, except for Gleason 4+3 (P = 0.662), as well across all health status groups. However, linear trends did not differ significantly between frail vs. nonfrail patients for both those categorized as low-risk (P = 0.446) and intermediate-risk (P = 0.208). Trends also did not differ between NCI 0 vs. 1 vs. >1 for low-risk PCa (P = 0.395). In the multivariable models, EM was associated with increasing age and being frail for men with both low- and intermediate risk disease. Conversely, EM selection was negatively associated with higher comorbidity score. CONCLUSIONS EM increased significantly over time for patients with low- and favorable intermediate-risk disease, with the most notable differences based on age and Gleason score. In contrast, trends in uptake of EM did not differ substantively by health status, suggesting that physicians may not be effectively incorporating patient health into PCa treatment decisions. Additional work is needed to develop interventions that recognize health status as an essential component of a risk-adapted approach.
Collapse
Affiliation(s)
| | - Hung-Jui Tan
- Department of Urology, University of North Carolina, Chapel Hill, NC
| | - Ibardo A Zambrano
- Department of Urology, University of North Carolina, Chapel Hill, NC
| | - Ram Sankar Basak
- Department of Urology, University of North Carolina, Chapel Hill, NC
| | | | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Soohyun Hwang
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| |
Collapse
|
10
|
Matthew-Onabanjo AN, Nortey G, Matulewicz RS, Basak R, Culton DA, Weaver KN, Gallagher KK, Tan HJ, Rose TL, Milowsky M, Bjurlin MA. Diversity, equity, and inclusion in genitourinary clinical trials leading to FDA novel drug approval: An assessment of the FDA center for drug evaluation and research drug trials snapshot. Curr Probl Cancer 2023; 47:100958. [PMID: 37084464 PMCID: PMC10523926 DOI: 10.1016/j.currproblcancer.2023.100958] [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] [Received: 01/02/2023] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 04/23/2023]
Abstract
To determine the distribution of race and ethnicity among genitourinary oncology trial participants leading to FDA approval of novel molecular entities/biologics. Secondarily, we evaluated whether the proportion of Black participants in clinical trials increased over time. We quired the FDA Center for Drug Evaluation and Research Drug Trials Snapshot (DTS) between 2015 and 2020 for urologic oncology clinical trials leading to FDA approval of novel drugs. Enrollment data was stratified by race and ethnicity. Cochran-Armitage Trend tests were used to examine changes in Black patient participation over years. Nine clinical trials were identified that led to FDA approval of 5 novel molecular entities for prostate and 4 molecular entities for urothelial carcinoma treatment. Trials for prostate cancer included 5202 participants of which 69.8% were White, 4.0% Black, 11.0% Asian, 3.6% Hispanic, <1% American Indian/Alaska Native or Native Hawaiian/Pacific Islander, 3% other. Trials in urothelial carcinoma had 704 participants of which 75.1% were male, 80.8% White, 2.3% Black, 2.4% Hispanic, <1% American Indian/Alaska Native or Native Hawaiian/Pacific Islander, 5% other. Black participation rates over time did not change for urothelial (P = 0.59) or the combined cancer cohort (P = 0.29). Prostate cancer enrollment trends among Black participant declined over time (P = 0.03). Participants in genitourinary clinical trials leading to FDA approval of novel drugs are overwhelmingly white. Involving stakeholders who represent the needs and interests of underrepresented populations in the design and implementation of clinical trials of novel agents may be a strategy to increase diversity, equity, and inclusion among genitourinary clinical trials.
Collapse
Affiliation(s)
| | - Gabrielle Nortey
- Department of Urology, University of North Carolina, Chapel Hill, NC
| | - Richard S Matulewicz
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | - Ramsankar Basak
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | - Donna A Culton
- Department of Dermatology, University of North Carolina, Chapel Hill, NC
| | - Kimberly N Weaver
- Division of Gastroenterology & Hepatology, University of North Carolina, Chapel Hill, NC
| | | | - Hung-Jui Tan
- Department of Urology, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Tracy L Rose
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC; Division of Oncology, University of North Carolina, Chapel Hill, NC
| | - Matthew Milowsky
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC; Division of Oncology, University of North Carolina, Chapel Hill, NC
| | - Marc A Bjurlin
- Department of Urology, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC.
| |
Collapse
|
11
|
Emmerling M, Tan HJ, Shirk J, Bjurlin M. Applications of 3-Dimensional Virtual Reality Models (Ceevra®) for Surgical Planning of Robotic Surgery. Urology Video Journal 2023. [DOI: 10.1016/j.urolvj.2023.100220] [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: 04/05/2023] Open
|
12
|
Satar SNA, Mogan S, Jaafar WPN, Maghalingam S, Affendi FAR, Ng CF, Khoo CS, Chee YC, Hod R, Tan HJ. Characteristics of electroencephalogram changes and correlation with seizures in hospitalised patients. Med J Malaysia 2023; 78:149-154. [PMID: 36988523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
INTRODUCTION Electroencephalogram (EEG) is an important investigational tool that is widely used in the hospital settings for numerous indications. The aim was to determine factors associated with abnormal EEG and its clinical correlations in hospitalised patients. MATERIALS AND METHODS Patients with at least one EEG recording were recruited. The EEG and clinical data were collated. RESULTS Two hundred and fifty patients underwent EEG and 154 (61.6%) were found to have abnormal EEG. The abnormal changes consist of theta activity (79,31.6%), delta activity (20, 8%), focal discharges (41,16.4%) and generalised discharges (14, 5.6%). Older patients had 3.481 higher risk for EEG abnormalities, p=0.001. Patients who had focal seizures had 2.240 higher risk of having EEG abnormalities, p<0.001. Low protein level was a risk for EEG abnormalities, p=0.003. CONCLUSION This study emphasised that an abnormal EEG remains a useful tool in determining the likelihood for seizures in a hospital setting. The risk factors for EEG abnormality in hospitalised patients were age, focal seizures and low protein level. The EEG may have an important role as part of the workup in hospitalised patients to aid the clinician to tailor their management in a holistic manner.
Collapse
Affiliation(s)
- S N A Satar
- Universiti Kebangsaan Malaysia, Faculty of Medicine, Department of Medicine, Kuala Lumpur, Malaysia
| | - S Mogan
- Universiti Kebangsaan Malaysia, Faculty of Medicine, Department of Medicine, Kuala Lumpur, Malaysia
| | - W P N Jaafar
- Universiti Kebangsaan Malaysia, Faculty of Medicine, Department of Medicine, Kuala Lumpur, Malaysia
| | - S Maghalingam
- Universiti Kebangsaan Malaysia, Faculty of Medicine, Department of Medicine, Kuala Lumpur, Malaysia
| | - F A R Affendi
- Universiti Kebangsaan Malaysia, Faculty of Medicine, Department of Medicine, Kuala Lumpur, Malaysia
| | - C F Ng
- Universiti Kebangsaan Malaysia, Faculty of Medicine, Department of Medicine, Kuala Lumpur, Malaysia
| | - C S Khoo
- Universiti Kebangsaan Malaysia, Faculty of Medicine, Department of Medicine, Kuala Lumpur, Malaysia
| | - Y C Chee
- Universiti Sains Malaysia, School of Medical Sciences, Department of Medicine, Kota Bahru, Malaysia
| | - R Hod
- Universiti Kebangsaan Malaysia, Faculty of Medicine, Department of Community Health, Kuala Lumpur, Malaysia
| | - H J Tan
- Universiti Kebangsaan Malaysia, Faculty of Medicine, Department of Medicine, Kuala Lumpur, Malaysia
| |
Collapse
|
13
|
Lim SH, Tan TL, Ngo PW, Lee LY, Ting SY, Tan HJ. Factors related to prehospital delay and decision delay among acute stroke patients in a district hospital, Malaysia. Med J Malaysia 2023; 78:241-249. [PMID: 36988537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
INTRODUCTION Time is the greatest challenge in stroke management. This study aimed to examine factors contributing to prehospital delay and decision delay among stroke patients. MATERIALS AND METHODS A cross-sectional study involving acute stroke patients admitted to Seri Manjung Hospital was conducted between August 2019 and October 2020 via faceto- face interview. Prehospital delay was defined as more than 120 minutes taken from recognition of stroke symptoms till arrival in hospital, while decision delay was defined as more than 60 minutes taken from recognition of stroke symptoms till decision was made to seek treatment. RESULTS The median prehospital delay of 102 enrolled patients was 364 minutes (IQR 151.5, 1134.3) while the median for decision delay was 120 minutes (IQR 30.0, 675.0). No history of stroke (adj. OR 4.15; 95% CI 1.21, 14.25; p=0.024) and unaware of thrombolysis service (adj. OR 17.12; 95% CI 1.28, 229.17; p=0.032) were associated with higher odds of prehospital delay, while Indian ethnicity (adj. OR 0.09; 95% CI 0.02, 0.52; p=0.007) was associated with lower odds of prehospital delay as compared to Malay ethnicity. On the other hand, higher National Institutes of Health Stroke Scale (NIHSS) score (adj. OR 0.86; 95% CI 0.78, 0.95; p=0.002) was associated with lower odds of decision delay. CONCLUSION Public awareness is crucial to shorten prehosital delay and decision delay for better patients' outcomes in stroke. Various public health campaigns are needed to improve the awareness for stroke.
Collapse
Affiliation(s)
- S H Lim
- Seri Manjung Hospital, Medical Department, Ministry of Health, Perak, Malaysia.
| | - T L Tan
- Tengku Ampuan Rahimah Hospital, Medical Department, Klang, Ministry of Health, Selangor, Malaysia
| | - P W Ngo
- Seri Manjung Hospital, Medical Department, Ministry of Health, Perak, Malaysia
| | - L Y Lee
- Seri Manjung Hospital, Medical Department, Ministry of Health, Perak, Malaysia
| | - S Y Ting
- Seri Manjung Hospital, Clinical Research Centre, Ministry of Health, Perak, Malaysia
| | - H J Tan
- Kuala Lumpur Hospital, Department of Neurology, Ministry of Health, Kuala Lumpur, Malaysia
| |
Collapse
|
14
|
Tan HJ, Chung AE, Gotz D, Deal AM, Heiling HM, Teal R, Vu MB, Meeks WD, Fang R, Bennett AV, Nielsen ME, Basch E. Electronic Health Record Use and Perceptions among Urologic Surgeons. Appl Clin Inform 2023; 14:279-289. [PMID: 37044288 PMCID: PMC10097476 DOI: 10.1055/s-0043-1763513] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Received: 08/26/2022] [Accepted: 01/19/2023] [Indexed: 04/14/2023] Open
Abstract
OBJECTIVE Electronic health records (EHRs) have become widely adopted with increasing emphasis on improving care delivery. Improvements in surgery may be limited by specialty-specific issues that impact EHR usability and engagement. Accordingly, we examined EHR use and perceptions in urology, a diverse surgical specialty. METHODS We conducted a national, sequential explanatory mixed methods study. Through the 2019 American Urological Association Census, we surveyed urologic surgeons on EHR use and perceptions and then identified associated characteristics through bivariable and multivariable analyses. Using purposeful sampling, we interviewed 25 urologists and applied coding-based thematic analysis, which was then integrated with survey findings. RESULTS Among 2,159 practicing urologic surgeons, 2,081 (96.4%) reported using an EHR. In the weighted sample (n = 12,366), over 90% used the EHR for charting, viewing results, and order entry with most using information exchange functions (59.0-79.6%). In contrast, only 35.8% felt the EHR increases clinical efficiency, whereas 43.1% agreed it improves patient care, which related thematically to information management, administrative burden, patient safety, and patient-surgeon interaction. Quantitatively and qualitatively, use and perceptions differed by years in practice and practice type with more use and better perceptions among more recent entrants into the urologic workforce and those in academic/multispecialty practices, who may have earlier EHR exposure, better infrastructure, and more support. CONCLUSION Despite wide and substantive usage, EHRs engender mixed feelings, especially among longer-practicing surgeons and those in lower-resourced settings (e.g., smaller and private practices). Beyond reducing administrative burden and simplifying information management, efforts to improve care delivery through the EHR should focus on surgeon engagement, particularly in the community, to boost implementation and user experience.
Collapse
Affiliation(s)
- Hung-Jui Tan
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Arlene E. Chung
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, United States
| | - David Gotz
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States
- School of Information and Library Science, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Allison M. Deal
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Hillary M. Heiling
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Randall Teal
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States
- Connected Health Applications and Interventions Core, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Maihan B. Vu
- Connected Health Applications and Interventions Core, University of North Carolina, Chapel Hill, North Carolina, United States
- Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, North Carolina, United States
| | - William D. Meeks
- Data Management and Statistical Analysis, American Urological Association, Linthicum, Maryland, United States
| | - Raymond Fang
- Data Management and Statistical Analysis, American Urological Association, Linthicum, Maryland, United States
| | - Antonia V. Bennett
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Matthew E. Nielsen
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Ethan Basch
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States
| |
Collapse
|
15
|
Michael J, Velazquez N, Renson A, Tan HJ, Rose TL, Osterman CK, Milowsky M, Kang SK, Huang WC, Bjurlin MA. Does histologic subtype impact overall survival in observed T1a kidney cancers compared with competing risks? Implications for biopsy as a risk stratification tool. Int J Urol 2022; 29:845-851. [PMID: 35474518 DOI: 10.1111/iju.14910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/17/2021] [Accepted: 04/10/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We sought to assess if adding a biopsy proven histologic subtype to a model that predicts overall survival that includes variables representing competing risks in observed, biopsy proven, T1a renal cell carcinomas, enhances the model's performance. METHODS The National Cancer Database was assessed (years 2004-2015) for patients with observed T1a renal cell carcinoma who had undergone renal mass biopsy. Kaplan-Meier curves were utilized to estimate overall survival stratified by histologic subtype. We utilized C-index from a Cox proportional hazards model to evaluate the impact of adding histologic subtypes to a model to predict overall survival for each stage. RESULTS Of 132 958 T1a renal masses identified, 1614 had biopsy proven histology and were managed non-operatively. Of those, 61% were clear cell, 33% papillary, and 6% chromophobe. Adjusted Kaplan-Meier curves demonstrated a difference in overall survival between histologic subtypes (P = 0.010) with greater median overall survival for patients with chromophobe (85.1 months, hazard rate 0.45, P = 0.005) compared to clear cell (64.8 months, reference group). Adding histology to a model with competing risks alone did not substantially improve model performance (C-index 0.65 vs 0.64 respectively). CONCLUSIONS Incorporation of histologic subtype into a risk stratification model to determine prognostic overall survival did not improve modeling of overall survival compared with variables representing competing risks in patients with T1a renal cell carcinoma managed with observation. These results suggest that performing renal mass biopsy in order to obtain tumor histology may have limited utility. Future studies should further investigate the overall utility of renal mass biopsy for observed T1a kidney cancers.
Collapse
Affiliation(s)
- Jamie Michael
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Nermarie Velazquez
- Division of Urologic Oncology, Department of Urology, NYU Langone Health, New York City, New York, USA
| | - Audrey Renson
- Department of Clinical Research, NYU Langone Hospital - Brooklyn, Brooklyn, New York, USA
| | - Hung-Jui Tan
- Department of Urology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Tracy L Rose
- Division of Oncology, Department of Medicine, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Chelsea K Osterman
- Division of Oncology, Department of Medicine, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Matthew Milowsky
- Division of Oncology, Department of Medicine, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Stella K Kang
- Department of Radiology, NYU Langone Health, New York City, New York, USA.,Department of Population Health, NYU School of Medicine, New York City, New York, USA
| | - William C Huang
- Division of Urologic Oncology, Department of Urology, NYU Langone Health, New York City, New York, USA
| | - Marc A Bjurlin
- Department of Urology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| |
Collapse
|
16
|
Chun DS, Hicks B, Hinton SP, Funk MJ, Gooden K, Keil AP, Tan HJ, Stürmer T, Lund JL. Comparison of Approaches for Measuring Adherence and Persistence to Oral Oncologic Therapies in Patients Diagnosed with Metastatic Renal Cell Carcinoma. Cancer Epidemiol Biomarkers Prev 2022; 31:893-899. [PMID: 35064061 DOI: 10.1158/1055-9965.epi-21-0341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/28/2021] [Accepted: 01/06/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Adherence and persistence studies face several methodologic difficulties, including short-term mortality. We compared approaches to quantify adherence and persistence to first line (1L) oral targeted therapy (TT) in patients diagnosed with metastatic renal cell carcinoma (mRCC). METHODS Patients with mRCC ages 66 years or more who initiated TTs within 4 months of diagnosis were identified in the Surveillance, Epidemiology, and End Results Medicare-linked database (2007-2015). Adherence [proportion of days covered (PDC) >80%] was calculated using (i) PDC with a fixed 6-month denominator including then excluding patients who died within the 6 months and (ii) PDC with a denominator measuring time on treatment. Risk of nonpersistence was obtained by censoring death or treating death as a competing risk using cumulative incidence functions. RESULTS Among 485 patients with mRCC initiating a 1L oral TT (sunitinib, 64%; pazopanib, 25%; other, 11%), 40% died within 6 months. Adherence was higher after restricting to patients who survived (60%) compared with including those patients and assigning zero days covered after death (47%). Risk of nonpersistence was higher when censoring patients at death, 0.91 [95% confidence interval (CI), 0.88-0.94], compared with treating death as a competing risk, 0.75 (95% CI, 0.71-0.79). CONCLUSIONS Different approaches to handling death resulted in different adherence and persistence estimates in the metastatic setting. Future studies should explicitly report the proportion of patient deaths over time and explore appropriate methods to account for death as competing risk. IMPACT Use of several approaches can provide a more comprehensive picture of medication-taking behavior in the metastatic setting where death is a major competing risk.
Collapse
Affiliation(s)
- Danielle S Chun
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Blánaid Hicks
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland
| | - Sharon Peacock Hinton
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Michele Jonsson Funk
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Kyna Gooden
- Bristol Meyers Squibb, Princeton Pike, New Jersey
| | - Alexander P Keil
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Hung-Jui Tan
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Til Stürmer
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|
17
|
Hicks BM, Chun DS, Peacock Hinton S, Hsu CD, Tan HJ, Lund JL. Patterns of first-line targeted therapy utilization and adherence among older adults diagnosed with metastatic renal cell carcinoma. J Geriatr Oncol 2022; 13:325-333. [PMID: 34782282 DOI: 10.1016/j.jgo.2021.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Received: 03/10/2021] [Revised: 10/25/2021] [Accepted: 11/03/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Despite the rapid approval of targeted therapies for metastatic renal cell carcinoma (mRCC) evidence on real world treatment patterns remains limited. This study evaluated patterns of first-line targeted therapy utilization and adherence in older adults, a population with a high burden of RCC. METHODS 2093 patients aged ≥66 years with a primary diagnosis of mRCC were identified from United States (US)-based cancer registry and administrative claims data (2007-2015). We included only patients with de novo disease. We assessed the initiation of first-line targeted therapy within four months of diagnosis and persistence and adherence to targeted therapy, using the proportion of days covered (PDC). Multivariable logistic regression yielded adjusted odds ratios (ORs) and 95% confidence intervals (CIs) to describe characteristics associated with targeted therapy versus no targeted therapy initiation and for high (≥80% PDC) versus low adherence. RESULTS 28.8% of patients received first-line targeted therapy within four months of diagnosis, with the proportion of patients receiving targeted therapy increasing over time. Older age (one-year increment OR:0.95 95%CI 0.93, 0.97), high comorbidity burden (OR:0.65 95%CI0.46, 0.93) and clear cell histology (OR:1.54 95%CI 1.19, 2.00) were associated with targeted therapy initiation. 48.2% of patients exhibited a high PDC to oral targeted therapy at 120 days, which was attenuated with inclusion of patients who died during the time period (34.2% PDC ≥80%). CONCLUSION Increasing age, high comorbidity burden and non-clear cell histology were associated with decreased targeted therapy initiation among patients with de novo mRCC. Our findings suggest adherence to oral therapies was low; future research exploring the mechanisms and impact of low adherence in this older patient population is warranted.
Collapse
Affiliation(s)
- Blánaid M Hicks
- Centre for Public Health, Queen's University Belfast, Belfast, UK..
| | - Danielle S Chun
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - Sharon Peacock Hinton
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina, Chapel Hill, NC, USA
| | - Christine D Hsu
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - Hung-Jui Tan
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| |
Collapse
|
18
|
McMahon S, Blalock S, Sox-Harris A, Reuland D, Bennett A, Nielsen ME, Basch E, Tan HJ. Targetable Action Points to Enhance Surgical Decision-Making. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.281] [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]
|
19
|
Rose TL, Harrison MR, Deal AM, Ramalingam S, Whang YE, Brower B, Dunn M, Osterman CK, Heiling HM, Bjurlin MA, Smith AB, Nielsen ME, Tan HJ, Wallen E, Woods ME, George D, Zhang T, Drier A, Kim WY, Milowsky MI. Phase II Study of Gemcitabine and Split-Dose Cisplatin Plus Pembrolizumab as Neoadjuvant Therapy Before Radical Cystectomy in Patients With Muscle-Invasive Bladder Cancer. J Clin Oncol 2021; 39:3140-3148. [PMID: 34428076 DOI: 10.1200/jco.21.01003] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
PURPOSE To evaluate the safety and efficacy of gemcitabine and cisplatin in combination with the immune checkpoint inhibitor pembrolizumab as neoadjuvant therapy before radical cystectomy (RC) in muscle-invasive bladder cancer. METHODS Patients with clinical T2-4aN0/XM0 muscle-invasive bladder cancer eligible for RC were enrolled. The initial six patients received lead-in pembrolizumab 200 mg once 2 weeks prior to pembrolizumab 200 mg once on day 1, cisplatin 70 mg/m2 once on day 1, and gemcitabine 1,000 mg/m2 once on days 1 and 8 every 21 days for four cycles. This schedule was discontinued for toxicity and subsequent patients received cisplatin 35 mg/m2 once on days 1 and 8 without lead-in pembrolizumab. The primary end point was pathologic downstaging (< pT2N0) with null and alternative hypothesis rates of 35% and 55%, respectively. Secondary end points were toxicity including patient-reported outcomes, complete pathologic response (pT0N0), event-free survival, and overall survival. Association of pathologic downstaging with programmed cell death ligand 1 staining was explored. RESULTS Thirty-nine patients were enrolled between June 2016 and March 2020 (72% cT2, 23% cT3, and 5% cT4a). Patients received a median of four cycles of therapy. All patients underwent RC except one who declined. Twenty-two of 39 patients (56% [95% CI, 40 to 72]) achieved < pT2N0 and 14 of 39 (36% [95% CI, 21 to 53]) achieved pT0N0. Most common adverse events (AEs) of any grade were thrombocytopenia (74%), anemia (69%), neutropenia (67%), and hypomagnesemia (67%). One patient had new-onset type 1 diabetes mellitus with ketoacidosis related to pembrolizumab and no patients required steroids for immune-related AEs. Clinicians consistently under-reported AEs when compared with patients. CONCLUSION Neoadjuvant gemcitabine and cisplatin plus pembrolizumab met its primary end point for improved pathologic downstaging and was generally safe. A global study of perioperative chemotherapy plus pembrolizumab or placebo is ongoing.
Collapse
Affiliation(s)
- Tracy L Rose
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Division of Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael R Harrison
- Division of Medical Oncology, Department of Medicine, Duke Cancer Institute, Duke University, Durham, NC
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sundhar Ramalingam
- Division of Medical Oncology, Department of Medicine, Duke Cancer Institute, Duke University, Durham, NC
| | - Young E Whang
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Division of Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Blaine Brower
- Division of Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mary Dunn
- Division of Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Chelsea K Osterman
- Division of Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Hillary M Heiling
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Marc A Bjurlin
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Angela B Smith
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew E Nielsen
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Hung-Jui Tan
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Eric Wallen
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael E Woods
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Daniel George
- Division of Medical Oncology, Department of Medicine, Duke Cancer Institute, Duke University, Durham, NC
| | - Tian Zhang
- Division of Medical Oncology, Department of Medicine, Duke Cancer Institute, Duke University, Durham, NC
| | - Anthony Drier
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - William Y Kim
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Division of Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew I Milowsky
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Division of Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| |
Collapse
|
20
|
Demzik A, Filippou P, Chew C, Reines K, Brown S, Wallen EM, Viprakasit D, Smith AB, Tan HJ. Linguistic Differences in Personal Statements of Urology Residency Applicants by Self-Reported Race and Ethnicity. Urology 2021; 162:137-143. [PMID: 34118231 DOI: 10.1016/j.urology.2021.05.047] [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: 03/18/2021] [Revised: 05/04/2021] [Accepted: 05/23/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess a potential source of bias that could contribute to underrepresentation of minorities in urology, we analyzed differences in linguistic characteristics in personal statements between urology residency applicants of various racial and ethnic groups. METHODS Personal statements submitted by urology residency applicants to a urology program were evaluated with Linguistic Inquiry and Word Count, a validated text analysis program. Analyzed statements and application characteristics were compared according to self-identified race/ethnicity of the applicant using multivariable analysis and independent sample T-tests. RESULTS Of 342 submitted personal statements, 181 applicants self-identified as White non-Hispanic, 86 as Asian, and 75 as "underrepresented in medicine" (URM) including Black and Hispanic/Latino applicants. Asian and URM applicants listed more research projects (11.7 and 12.9 vs 8.8, P = .01) and URM applicants had slightly lower USMLE Step 1 scores (238.5 vs 244.6, P = .01) compared to White applicants. When evaluating personal statements, all applicants wrote with the same degree of analytical thinking. Asian applicants scored lower in authenticity (P = .03) and emotional tone (P = .04) while URM applicants scored higher in clout (P = .04) compared to White applicants. In use of pronouns, Asian applicants used 'we/us/our' more often (P < .01), URM applicants used 'you' more often (P = .02), and White applicants used 'I' more often (P = .01). CONCLUSION Significant linguistic differences exist among urology personal statements by racial/ethnic groups that may perpetuate stereotypes and bias in the application process. Appreciating these differences may help applicants avoid possibly detrimental linguistics and help residency programs recruit and support urology applicants from underrepresented backgrounds.
Collapse
Affiliation(s)
- Alysen Demzik
- Department of Urology, University of North Carolina, Chapel Hill, NC.
| | | | | | - Katy Reines
- Department of Urology, University of North Carolina, Chapel Hill, NC
| | - Stephanie Brown
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Eric M Wallen
- Department of Urology, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, Multidisciplinary Genitourinary Oncology, Chapel Hill, NC
| | - Davis Viprakasit
- Department of Urology, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, Multidisciplinary Genitourinary Oncology, Chapel Hill, NC
| | - Angela B Smith
- Department of Urology, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, Multidisciplinary Genitourinary Oncology, Chapel Hill, NC
| | - Hung-Jui Tan
- Department of Urology, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, Multidisciplinary Genitourinary Oncology, Chapel Hill, NC
| |
Collapse
|
21
|
Garg T, Johns A, Young AJ, Nielsen ME, Tan HJ, McMullen CK, Kirchner HL, Cohen HJ, Murphy TE. Geriatric conditions and treatment burden following diagnosis of non-muscle- invasive bladder cancer in older adults: A population-based analysis. J Geriatr Oncol 2021; 12:1022-1030. [PMID: 33972184 DOI: 10.1016/j.jgo.2021.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 12/17/2020] [Revised: 03/23/2021] [Accepted: 04/27/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Treatment burden is emerging as an important patient-centered outcome for older adults with cancer who concurrently manage geriatric conditions. Our objective was to evaluate the contribution of geriatric conditions to treatment burden in older adults with non-muscle invasive bladder cancer (NMIBC). METHODS We identified 73,395 Medicare beneficiaries age 66+ diagnosed with NMIBC (Stage <II) in SEER-Medicare (2001-2014). The primary outcome was treatment burden, defined as health system contact days in the year following NMIBC diagnosis. Explanatory variables were the following geriatric conditions: multimorbidity (≥ 2 chronic conditions), functional dependency, falls, depression, cognitive impairment, weight loss, and urinary incontinence. We used negative binomial regression to model the association between individual geriatric conditions and treatment burden while adjusting for covariates. RESULTS At baseline, 64% had multimorbidity and median 3 conditions (IQR 0-5). Prevalence of other geriatric conditions ranged from 5.9%-15.2%. Adjusted mean health system contact was 8.9 days (95% CI 8.6-9.2). Multimorbidity had the largest effect size (adjusted mean 11.8 contact days (95% CI 8.3-8.8)). Each additional chronic condition conferred a 13% increased average number of health system contact (adjusted IRR 1.132, 95% CI 1.129-1.135). Regardless of number of chronic conditions, rural patients consistently had more treatment burden than urban counterparts. DISCUSSION In this population-based cohort of older NMIBC patients, multimorbidity and rurality were strongly associated with treatment burden in the year following NMIBC diagnosis. These findings highlight the need for interventions that reduce treatment burden due to geriatric conditions among the growing population of older adults with cancer, particularly in rural areas.
Collapse
Affiliation(s)
- Tullika Garg
- Department of Urology, Geisinger, Danville, PA, United States of America; Department of Population Health Sciences, Geisinger, Danville, PA, United States of America.
| | - Alicia Johns
- Department of Population Health Sciences, Geisinger, Danville, PA, United States of America; Biostatistics Core, Geisinger, Danville, PA, United States of America
| | - Amanda J Young
- Department of Population Health Sciences, Geisinger, Danville, PA, United States of America; Biostatistics Core, Geisinger, Danville, PA, United States of America
| | - Matthew E Nielsen
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America; Departments of Epidemiology and Health Policy & Management, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, United States of America; Center for Health Research, Kaiser Permanente Northwest, Portland, OR, United States of America
| | - Hung-Jui Tan
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Carmit K McMullen
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, United States of America
| | - H Lester Kirchner
- Department of Population Health Sciences, Geisinger, Danville, PA, United States of America; Biostatistics Core, Geisinger, Danville, PA, United States of America
| | - Harvey J Cohen
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, United States of America
| | - Terrence E Murphy
- Section of Geriatrics, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States of America
| |
Collapse
|
22
|
Rose TL, Harrison MR, Deal AM, Osterman CK, Ramalingam S, Whang YE, Brower BY, Bjurlin M, Smith AB, Nielsen ME, Tan HJ, Wallen EM, George DJ, Zhang T, Drier A, Kim WY, Milowsky MI. Phase II study of gemcitabine and split-dose cisplatin plus pembrolizumab as neoadjuvant therapy prior to radical cystectomy (RC) in patients with muscle-invasive bladder cancer (MIBC). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.396] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
396 Background: Cisplatin-based neoadjuvant chemotherapy is standard of care in MIBC with improved pathologic response and overall survival (OS) compared to RC alone. Pembrolizumab (pembro) is active in high-risk non-muscle invasive and metastatic bladder cancer and is generally well tolerated. This phase II trial evaluated the safety and efficacy of gemcitabine and split-dose cisplatin (GC) + pembro as neoadjuvant therapy prior to RC (NCT02690558). Methods: Patients with clinical T2-4a N0/X M0 urothelial carcinoma of the bladder eligible for RC were enrolled. Patients received pembro 200mg on day 1 with cisplatin 35mg/m2 and gemcitabine 1000mg/m2 on days 1 and 8 every 3 weeks for 4 cycles, followed by RC within 4-8 weeks. The first 6 patients received full-dose cisplatin (70mg/m2 on day 1) and a lead-in pembro dose; this schedule was discontinued for excess toxicity. Primary endpoint was pathologic downstaging rate ( < pT2) with the null and alternative hypothesis rates = 35% and 55%, respectively. Secondary endpoints were toxicity, pT0 rate, event free survival, and OS. Exploratory objectives include association of response with molecular subtype and post-treatment changes in immune microenvironment (predicted neoantigens, immune gene expression, and T cell receptor repertoire). Results: Between May 2016 and July 2020, 39 patients were enrolled (72% cT2, 23% cT3, 5% cT4a) with a median age of 66 and 82% male. Patients received a median of 4 cycles of therapy. All patients underwent RC except one who declined but is included in intention to treat analysis. Rate of < pT2N0 was 56% (22/39) and pT0N0 rate was 36% (14/39). Most common adverse events (AEs) of any grade were thrombocytopenia (29/39; 74%), anemia (27/39; 69%), neutropenia (26/39; 67%), and hypomagnesemia (26/39; 67%). Most common grade 3/4 AEs were neutropenia (16/39; 41%), thrombocytopenia (13/39; 33%), febrile neutropenia (5/39; 13%), and anemia (4/39; 10%). One patient had new onset type 1 diabetes mellitus with ketoacidosis related to pembrolizumab and no patients required steroids for immune-related AEs. Nine patients (23%) discontinued GC + pembro due to AEs, including 4 of the 6 patients who received full-dose cisplatin with pembro lead-in. Survival data are not yet mature and correlative studies are ongoing. Conclusions: Neoadjuvant GC + pembro was generally safe and met its primary endpoint for improved pathologic downstaging. Correlative analyses are ongoing. Additional investigation of this combination is warranted. Clinical trial information: NCT02690558.
Collapse
Affiliation(s)
- Tracy L Rose
- The University of North Carolina at Chapel Hill (UNC-CH) School of Medicine and UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Michael Roger Harrison
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Duke University, Durham, NC
| | - Allison Mary Deal
- Lineberger Comprehensive Cancer Center at University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Chelsea K. Osterman
- Division of Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Young E. Whang
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Blaine Y Brower
- University of North Carolina Department of Medicine, Division of Hematology/Oncology, Chapel Hill, NC
| | - Marc Bjurlin
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Angela B. Smith
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Hung-Jui Tan
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Eric M. Wallen
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Daniel J. George
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Duke University, Durham, NC
| | - Tian Zhang
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Duke University, Durham, NC
| | - Anthony Drier
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - William Y. Kim
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Matthew I. Milowsky
- University of North Carolina Department of Medicine, Division of Hematology/Oncology, Chapel Hill, NC
| |
Collapse
|
23
|
Gurjar MS, Osterman CK, Nyrop KA, Bjurlin M, Tan HJ, Nielsen ME, Wallen EM, Milowsky MI, Muss HB, Smith AB. The association of malnutrition and sarcopenia with geriatric assessment impairment and outcomes in patients with bladder cancer undergoing cystectomy. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.423] [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] [Indexed: 11/20/2022] Open
Abstract
423 Background: Malnutrition and sarcopenia are linked to decreased functional status in older adults with malignancy, but their effect on geriatric assessment (GA) impairment in patients with bladder cancer (BC) undergoing radical cystectomy (RC) is unknown. We investigated the association between malnutrition and sarcopenia with GA impairment and postoperative outcomes. Methods: Patients with BC undergoing RC between 2012 – 2019 were enrolled in a prospective cohort study of GA before RC. Malnutrition was evaluated by a dietitian pre-RC per the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition diagnostic criteria. Sarcopenia, defined by a skeletal muscle index of < 52.4 cm2/m2 in males and < 38.5 cm2/m2 in females, was determined using SliceOmatic software to analyze pre-RC CT images at the L3 vertebra. Patients with vs without malnutrition and those with vs without sarcopenia were compared using Fisher’s exact and Wilcoxon rank sum tests. Results: Of 73 patients, 59 had GA + nutrition evaluation and 51 had GA + sarcopenia assessment (overall median age 68 [IQR 62-74], 76% male). The prevalence of malnutrition was 7% and sarcopenia was 63%. A numerically greater proportion of patients with malnutrition or sarcopenia were impaired on ≥ 1 GA measure compared to those without malnutrition (100% vs 78%, p=0.57) or sarcopenia (78% vs 68%, p=0.52), although this was not statistically significant (Table). Median hospital length of stay (LOS) was increased for patients with vs without sarcopenia (4 vs 5 days, p=0.005). Post-RC complication rate was similar for patients with vs without malnutrition (100% vs 75%, p=0.56) and patients with vs without sarcopenia (81% vs 74%, p=0.73), but malnourished patients were more likely to have Clavien-Dindo grade 3+ complications than those without malnutrition (100% vs 27%, p = 0.009). Conclusions: In our cohort of patients with BC undergoing RC, those with malnutrition or sarcopenia may have an increased rate of impairment on GA compared to those without malnutrition or sarcopenia. Sarcopenia was associated with increased LOS while malnutrition was associated with increased major complications. Our results are limited by small sample size, and future work is needed to elucidate whether addressing these modifiable factors improves functional status and postoperative outcomes. Research Sponsor: U.S. National Institutes of Health[Table: see text]
Collapse
Affiliation(s)
| | - Chelsea K. Osterman
- Division of Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kirsten A. Nyrop
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Marc Bjurlin
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Hung-Jui Tan
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Eric M. Wallen
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew I. Milowsky
- University of North Carolina Department of Medicine, Division of Hematology/Oncology, Chapel Hill, NC
| | | | - Angela B. Smith
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| |
Collapse
|
24
|
Michael J, Khandani AH, Basak R, Tan HJ, Royce TJ, Wallen E, Whang Y, Rose TL, Milowsky M, Bjurlin MA. Patterns of Recurrence, Detection Rates, and Impact of 18-F Fluciclovine PET/CT on the Management of Men With Recurrent Prostate Cancer. Urology 2021; 155:192-198. [PMID: 33516829 DOI: 10.1016/j.urology.2021.01.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To evaluate the characteristics of FACBC PET/CT in detecting recurrent prostate cancer after radiation or prostatectomy. The secondary aim was to determine the impact of FACBC PET/CT on radiation treatment recommendations in men with biochemical recurrence postprostatectomy. METHODS This is a single center retrospective study of men who underwent an FACBC PET/CT for rising PSA after definitive prostate cancer therapy. Detection rates in men with recurrence following any definitive treatment were compared at different PSA levels and anatomical sites. Radiotherapy treatment recommendations for patients postprostatectomy based on conventional imaging findings were compared to recommendations based on FACBC PET/CT findings. RESULTS A total of 103 men underwent imaging with FACBC PET/CT. 74.8% (77) had lesions consistent with sites of prostate cancer recurrence. At PSA thresholds of <1, 1-2, and >2 ng/mL lesions were detected in 35.5%, 63.6%, and 95.2% of patients respectively (P <.001). The most common site of recurrence was outside of the pelvis (37). Detection of extraprostatic or extrapelvic recurrence was observed in 45.5% of men in the PSA tertile <1ng/mL. FACBC PET/CT results led to changes to the recommended radiotherapy treatment plan in 44.1% (15/34) of men with recurrence following radical prostatectomy. CONCLUSION FACBC PET/CT demonstrated increased detection of recurrent prostate cancer with increasing PSA levels. Most recurrences were found outside the pelvis. Results of FACBC PET/CT changed radiotherapy management decisions in men treated with prostatectomy, supporting its use in localizing sites of disease recurrence in men with prostate cancer.
Collapse
Affiliation(s)
- Jamie Michael
- University of North Carolina, School of Medicine, NC
| | - Amir H Khandani
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Ramsankar Basak
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Hung-Jui Tan
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Trevor J Royce
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Eric Wallen
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Young Whang
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Medicine-Division of Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Tracy L Rose
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Medicine-Division of Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew Milowsky
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Medicine-Division of Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Marc A Bjurlin
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| |
Collapse
|
25
|
Michael J, Velazquez N, Renson A, Tan HJ, Rose TL, Osterman C, Milowsky M, Raynor M, Kang SK, Huang WC, Bjurlin MA. Overall Survival of Biopsy-confirmed T1B and T2A Kidney Cancers Managed With Observation: Prognostic Value of Tumor Histology. Clin Genitourin Cancer 2021; 19:280-287. [PMID: 33582101 DOI: 10.1016/j.clgc.2020.12.006] [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: 09/02/2020] [Revised: 12/29/2020] [Accepted: 12/31/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The natural history of T1b (4-7 cm) or T2a (> 7-10 cm) kidney cancers managed with observation is not well-understood. The aim of our study was to determine if the addition of histologic subtype to a predictive model of overall survival (OS) that includes covariates for competing risks in observed, biopsy-proven, T1b and T2a renal cell carcinomas (RCCs) improves the model's performance. MATERIALS AND METHODS We queried the National Cancer Database for patients with biopsy-proven stage T1b or T2a RCC and managed nonoperatively between 2004 and 2015. OS was estimated by Kaplan-Meier curves based on histologic subtype. The concordance index (c-index) from a Cox proportional hazards model was used to estimate the extent to which histologic subtypes predict survival for each stage when included in a model along with competing risks of age, gender, race/ethnicity, insurance status, area-level socioeconomic indicators, Charlson-Deyo index, and tumor grade. RESULTS A total of 937 patients (754 with T1b and 185 with T2a) with biopsy-proven RCC were identified. Kaplan-Meier analysis suggested differences in OS by histologic subtype where sarcomatoid, followed by clear cell, papillary, and chromophobe, had the highest mortality risk at 1, 3, and 5 years. However, there was marginal improvement in the multivariable model of OS using competing risks and histology (c-index, 0.64 and 0.697) compared with competing risks alone (c-index, 0.631 and 0.671) for T1b and T2a RCCs, respectively. CONCLUSIONS In patients with T1b or T2a RCC managed with observation, incorporation of histologic subtype into a risk-stratification model to determine prognostic OS did not improve modeling of OS compared with variables representing competing risks. Histologic subtype of observed T1b and T2a RCC appears to have prognostic OS value when not considering competing risks. These findings may impact the usefulness of renal biopsy to inform decision-making when managing patients with T1b and T2a renal tumors with observation.
Collapse
Affiliation(s)
- Jamie Michael
- School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Nermarie Velazquez
- Division of Urologic Oncology, Department of Urology, NYU Langone Health, New York, NY
| | - Audrey Renson
- Department of Clinical Research, NYU Langone Hospital - Brooklyn, Brooklyn, NY
| | - Hung-Jui Tan
- Department of Urology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Tracy L Rose
- Division of Oncology, Department of Medicine, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Chelsea Osterman
- Division of Oncology, Department of Medicine, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Matthew Milowsky
- Division of Oncology, Department of Medicine, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Matt Raynor
- Department of Urology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Stella K Kang
- Department of Radiology, NYU Langone Health, New York, NY; Department of Population Health, NYU School of Medicine, New York, NY
| | - William C Huang
- Division of Urologic Oncology, Department of Urology, NYU Langone Health, New York, NY
| | - Marc A Bjurlin
- Department of Urology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC.
| |
Collapse
|
26
|
Dworsky JQ, Shellito AD, Childers CP, Copeland TP, Maggard-Gibbons M, Tan HJ, Saliba D, Russell MM. Association of Geriatric Events With Perioperative Outcomes After Elective Inpatient Surgery. J Surg Res 2020; 259:192-199. [PMID: 33302219 DOI: 10.1016/j.jss.2020.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 06/10/2020] [Revised: 10/14/2020] [Accepted: 11/01/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Older adults undergoing surgery are at risk for geriatric events (GEs: delirium, dehydration, falls or fractures, failure to thrive, and pressure ulcers). The prevalence and association of GEs with clinical outcomes after elective surgery is unclear. MATERIALS AND METHODS Using the 2013-2014 National Inpatient Sample, we analyzed hospital admissions for the five most common elective procedures (total knee arthroplasty, right hemicolectomy, carotid endarterectomy, aortic valve replacement, and radical prostatectomy) in older adults (age ≥ 65). Our primary variable of interest was presence of any GE. Logistic regression estimated the association of GEs with (1) age group and (2) perioperative outcomes (mortality, postoperative complications, prolonged length of stay, and discharge to skilled nursing facility). RESULTS Of 1,255,120 admissions, 66.5% were aged ≥65. The overall rate of any GE was 2.4% and increased with age (55-64 y: 1.5%; 65-74: 2.2%; ≥75: 4.1%; P < 0.001). After adjustment, the probability of any GE increased with age (P < 0.001). Rates of GEs varied by procedure (P < 0.001). In comparison with admissions with no GEs, one or more GE was associated with higher probability of worse outcomes including mortality, postoperative complications, prolonged length of stay, and discharge to skilled nursing facility (all P < 0.001). In addition, there was a dose-dependent relationship between GEs and these poor perioperative outcomes. CONCLUSIONS GEs are strongly associated with poor perioperative outcomes. Efforts should focus on mutable factors responsible for GEs to optimize surgical care for older adults.
Collapse
Affiliation(s)
- Jill Q Dworsky
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California.
| | - Adam D Shellito
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance California.
| | | | - Timothy P Copeland
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
| | | | - Hung-Jui Tan
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Debra Saliba
- Los Angeles VA GRECC & UCLA Borun Center, Los Angeles, California
| | - Marcia M Russell
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California
| |
Collapse
|
27
|
Gessner KH, Jung J, Cook HE, Graves JL, McNaull P, Chidgey B, Mann J, Woody N, Deal AM, Coward RM, Figler B, Borawski K, Bjurlin MA, Raynor M, Tan HJ, Viprakasit D, Wallen EM, Nielsen ME, Smith AB. Implementation of Postoperative Standard Opioid Prescribing Schedules Reduces Opioid Prescriptions Without Change in Patient-reported Pain Outcomes. Urology 2020; 148:126-133. [PMID: 33217455 DOI: 10.1016/j.urology.2020.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/31/2020] [Accepted: 11/05/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To implement Standard Opioid Prescribing Schedules (SOPS) based on opioid use following urologic surgeries and to evaluate how evidence-based prescribing schedules affect opioid use and patient reported outcomes. METHODS Patients who underwent urologic surgeries within 6 procedure subtypes at UNC Health during the 2 study time periods ("pre-SOPS": 7/2017-1/2018, "post-SOPS": 7/2018-1/2019) were invited to complete a survey analyzing postoperative opioid usage, storage and disposal, and patient reported outcomes (including pain interference using a validated questionnaire). A pharmacy database provided medication prescribing data and patient demographics. During the pre-SOPS time period, baseline outcomes were measured. Following the pre-SOPS period, usage amounts were analyzed and Standard Opioid Prescribing Schedules were developed to guide prescriptions during the post-SOPS period. Descriptive summary statistics and appropriate t test or r2 were calculated. RESULTS A total of 438 patients within 6 procedure types completed the survey (pre-SOPS: 282 patients, post-SOPS: 156 patients). Pre-SOPS, patients were prescribed significantly more 5-mg oxycodone tablets than used (20.9 vs 7.8, P <.001). Post-SOPS, compared to pre-SOPS amounts, patients were prescribed significantly fewer tablets (12.7 vs 20.9, P <.001) and used fewer tablets (5.3 vs 7.8, P = .003). No difference was observed in pain interference (average t-score (standard deviation): 54.33 (10.9) pre-SOPS vs 55.89 (9.1) post-SOPS, P = .125) or patient satisfaction (95% pre-SOPS vs 94% post-SOPS). CONCLUSION Adherence to data-driven postoperative opioid prescribing schedules reduce opioid prescriptions and use without compromising pain interference or patient satisfaction. These results have important implications for urologists' ability to decrease opioid prescriptions and fight the opioid epidemic.
Collapse
Affiliation(s)
- Kathryn H Gessner
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Jaehyuk Jung
- University of North Carolina School of Pharmacy, Chapel Hill, NC
| | - Hannah E Cook
- University of North Carolina School of Pharmacy, Chapel Hill, NC
| | - J Lee Graves
- University of North Carolina School of Medicine, Chapel Hill, NC
| | - Peggy McNaull
- Department of Anesthesia, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Brooke Chidgey
- Department of Anesthesia, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jami Mann
- Department of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Nathan Woody
- Department of Anesthesia, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - R Matthew Coward
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Bradley Figler
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kristy Borawski
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Marc A Bjurlin
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Mathew Raynor
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Hung-Jui Tan
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Davis Viprakasit
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Eric M Wallen
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Matthew E Nielsen
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Angela B Smith
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| |
Collapse
|
28
|
Demzik A, Filippou P, Chew C, Deal A, Mercer E, Mahajan S, Wallen EM, Tan HJ, Smith AB. Gender-Based Differences in Urology Residency Applicant Personal Statements. Urology 2020; 150:2-8. [PMID: 33035562 PMCID: PMC7536514 DOI: 10.1016/j.urology.2020.08.066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 04/30/2020] [Revised: 07/26/2020] [Accepted: 08/04/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To gain insight into the perceptions of urology held by medical students as they enter the field, we analyzed the linguistic characteristics and gender differences in personal statements written by urology residency program applicants. METHODS Personal statements were abstracted from residency applications to a urology residency program. Linguistic Inquiry and Word Count, a validated text analysis software, characterized the linguistic content of the statements. Analyzed statements were compared according to gender of the applicant using multivariate analysis, examining the association of applicant gender and statement characteristics. Multivariate analysis was also performed to determine the association of personal statement characteristics with matching into urology residency. RESULTS Of 342 analyzed personal statements, no significant difference was found in statement characteristics between matched and unmatched applicants. Male and female applicants wrote with the same degree of overall analytical thinking, authenticity, and emotional tone. Clout, a measure of portrayed confidence, was low for both genders. Female applicants used more social and affective process words. Male applicants used more words indicating a sense of community and acceptance. Female applicants had more references to women within their statements. CONCLUSION Significant linguistic differences exist among personal statements written by men and women applying to urology residency. Word usage differences follow societal gender norms. Statement content demonstrates a difference between genders in perceived sense of belonging, highlighting the importance of gender concordant mentorship within the field.
Collapse
Affiliation(s)
- Alysen Demzik
- Department of Urology, University of North Carolina, Chapel Hill, NC
| | - Pauline Filippou
- Department of Urology, University of North Carolina, Chapel Hill, NC
| | | | - Allison Deal
- Multidisciplinary Genitourinary Oncology, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Emily Mercer
- Department of Urology, University of North Carolina, Chapel Hill, NC
| | - Sejal Mahajan
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Eric M Wallen
- Department of Urology, University of North Carolina, Chapel Hill, NC; Multidisciplinary Genitourinary Oncology, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Hung-Jui Tan
- Department of Urology, University of North Carolina, Chapel Hill, NC; Multidisciplinary Genitourinary Oncology, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Angela B Smith
- Department of Urology, University of North Carolina, Chapel Hill, NC; Multidisciplinary Genitourinary Oncology, Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
| |
Collapse
|
29
|
Michael J, Bjurlin M, Chew C, Mark Wallen E, Tan HJ. Does Lesion Location Impact Prostate Cancer Detection by MRI Ultrasound Fusion Guided Prostate Biopsy? J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.442] [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]
|
30
|
Tan HJ, Zhou X, Spratte BN, McMahon S, Nielsen ME, Lund J, Harris AHS, Smith AB, Basch E. Patient Reported vs Claims Based Measures of Health for Modeling Life Expectancy in Men with Prostate Cancer. J Urol 2020; 205:434-440. [PMID: 32909877 DOI: 10.1097/ju.0000000000001355] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE Life expectancy has become a core consideration in prostate cancer care. While multiple prediction tools exist to support decision making, their discriminative ability remains modest, which hampers usage and utility. We examined whether combining patient reported and claims based health measures into prediction models improves performance. MATERIALS AND METHODS Using SEER (Surveillance, Epidemiology, and End Results)-CAHPS (Consumer Assessment of Healthcare Providers and Systems) we identified men 65 years old or older diagnosed with prostate cancer from 2004 to 2013 and extracted 4 types of data, including demographics, cancer information, claims based health measures and patient reported health measures. Next, we compared the performance of 5 nested competing risk regression models for other cause mortality. Additionally, we assessed whether adding new health measures to established prediction models improved discriminative ability. RESULTS Among 3,240 cases 246 (7.6%) died of prostate cancer while 631 (19.5%) died of other causes. The National Cancer Institute Comorbidity Index score was associated but weakly correlated with patient reported overall health (p <0.001, r=0.21). For predicting other cause mortality the 10-year area under the receiver operating characteristic curve improved from 0.721 (demographics only) to 0.755 with cancer information and to 0.777 and 0.812 when adding claims based and patient reported health measures, respectively. The full model generated the highest value of 0.820. Models based on existing tools also improved in their performance with the incorporation of new data types as predictor variables (p <0.001). CONCLUSIONS Prediction models for life expectancy that combine patient reported and claims based health measures outperform models that incorporate these measures separately. However, given the modest degree of improvement, the implementation of life expectancy tools should balance model performance with data availability and fidelity.
Collapse
Affiliation(s)
- Hung-Jui Tan
- Department of Urology, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
| | - Xi Zhou
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
| | - Brooke N Spratte
- School of Medicine, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
| | - Stephen McMahon
- School of Medicine, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
| | - Matthew E Nielsen
- Department of Urology, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
| | - Jennifer Lund
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
| | - Alex H S Harris
- Department of Surgery, Stanford University, Stanford, California
| | - Angela B Smith
- Department of Urology, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
| | - Ethan Basch
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina.,Department of Internal Medicine, Division of Oncology, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
| |
Collapse
|
31
|
Hayon S, Deal A, Tan HJ, Namboodri B, Gan Z, Wood C, Pruthi R. Is the relative value of surgeon effort equal across surgical specialties? Surgery 2020; 168:365-370. [DOI: 10.1016/j.surg.2020.04.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 04/02/2020] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
|
32
|
Smith AB, Samuel CA, McCabe SD, Deal A, Jonsson M, Mueller DE, Mahbooba ZM, Bennett AV, Chung AE, Nielsen ME, Tan HJ, Wallen E, Pruthi R, Wang A, Basch E, Reeve BB, Chen RC. Feasibility and delivery of patient-reported outcomes in clinical practice among racially diverse bladder and prostate cancer patients. Urol Oncol 2020; 39:77.e1-77.e8. [PMID: 32819814 DOI: 10.1016/j.urolonc.2020.06.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 03/26/2020] [Revised: 05/26/2020] [Accepted: 06/27/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess the feasibility of enrollment and collecting patient-reported outcome (PRO) data as part of routine clinical urologic care for bladder and prostate cancer patients and examine overall patterns and racial variations in PRO use and symptom reports over time. SUBJECTS/PATIENTS AND METHODS We recruited 76 patients (n = 29 Black and n = 47 White) with prostate or bladder cancer at a single, comprehensive cancer center. The majority of prostate cancer patients had intermediate risk (57%) disease and underwent either radiation or prostatectomy. Over half (58%) of bladder cancer patients had muscle invasive disease and underwent cystectomy. Patients were asked to complete PRO symptom surveys using their preferred mode [web- or phone-based interactive voice response (IVR)]. Symptom summary reports were shared with providers during visits. Surveys were completed at 3 time points and assessed urinary, sexual, gastrointestinal, anxiety/depression, and sleep symptoms. Feasibility of enrollment and survey completion were calculated, and linear mixed effects models estimated differences in outcomes by race and time. RESULTS Sixty three percent of study participants completed all PRO measures at all 3 time points. Black patients were more likely to select IVR as their survey mode (40% vs. 13%, P < 0.05), and less likely to complete all surveys (55% vs. 74%, P = 0.13). Patients using IVR were also less likely to complete all surveys (41% vs. 69%, P = 0.046). CONCLUSIONS Reported preferences for survey mode and completion rates differ by race, which may influence survey completion rates and highlight potential obstacles for equitable implementation of PROs into clinical care.
Collapse
Affiliation(s)
- Angela B Smith
- University of North Carolina, Department of Urology, Chapel Hill, NC; University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
| | - Cleo A Samuel
- University of North Carolina, Department of Urology, Chapel Hill, NC; University of North Carolina, Department of Health Policy and Management, Chapel Hill, NC
| | - Sean D McCabe
- University of North Carolina, Lineberger Comprehensive Cancer Center, Biostatistics Core, Chapel Hill, NC; University of North Carolina, Department of Biostatistics, Chapel Hill, NC
| | - Allison Deal
- University of North Carolina, Lineberger Comprehensive Cancer Center, Biostatistics Core, Chapel Hill, NC
| | - Mattias Jonsson
- University of North Carolina, Department of Biostatistics, Chapel Hill, NC
| | - Dana E Mueller
- University of North Carolina, Department of Urology, Chapel Hill, NC; University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Zahra M Mahbooba
- University of North Carolina, Lineberger Comprehensive Cancer Center, Biostatistics Core, Chapel Hill, NC
| | - Antonia V Bennett
- University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; University of North Carolina, Department of Health Policy and Management, Chapel Hill, NC
| | - Arlene E Chung
- University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; University of North Carolina at Chapel Hill School of Medicine, Departments of Medicine and Pediatrics, Chapel Hill, NC
| | - Matthew E Nielsen
- University of North Carolina, Department of Urology, Chapel Hill, NC; University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; University of North Carolina, Department of Health Policy and Management, Chapel Hill, NC; University of North Carolina, Department of Health Policy and Management, Chapel Hill, NC; Kaiser Permanente Center for Health Research, Portland, OR
| | - Hung-Jui Tan
- University of North Carolina, Department of Urology, Chapel Hill, NC; University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Eric Wallen
- University of North Carolina, Department of Urology, Chapel Hill, NC; University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Raj Pruthi
- University of California- San Francisco, San Francisco, CA
| | - Andrew Wang
- University of North Carolina, Department of Urology, Chapel Hill, NC; University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Ethan Basch
- University of North Carolina, Department of Urology, Chapel Hill, NC; University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; University of North Carolina at Chapel Hill School of Medicine, Department of Medicine, Division of Hematology/Oncology, Chapel Hill, NC
| | - Bryce B Reeve
- Duke University School of Medicine, Department of Population Health Sciences, Durham, NC
| | - Ronald C Chen
- University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC; University of North Carolina, Lineberger Comprehensive Cancer Center, Biostatistics Core, Chapel Hill, NC; University of Kansas, Department of Radiation Oncology, Kansas City, KS
| |
Collapse
|
33
|
Taylor J, Becher E, Wysock JS, Lenis AT, Litwin MS, Jipp J, Langenstroer P, Johnson S, Bjurlin MA, Tan HJ, Lane BR, Huang WC. Primary Robot-assisted Retroperitoneal Lymph Node Dissection for Men with Nonseminomatous Germ Cell Tumor: Experience from a Multi-institutional Cohort. Eur Urol Focus 2020; 7:1403-1408. [PMID: 32682794 DOI: 10.1016/j.euf.2020.06.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Received: 03/23/2020] [Revised: 05/26/2020] [Accepted: 06/22/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Primary robot-assisted retroperitoneal lymph node dissection (RA-RPLND) for men with nonseminomatous germ cell tumor (NSGCT) is an alternative to open RPLND for stage I and select stage II patients. OBJECTIVE To report the complication rates and oncologic outcomes from a multi-institutional series, and to estimate reduction in chemotherapy by using upfront minimally invasive surgery. DESIGN, SETTING, AND PARTICIPANTS A retrospective chart review of men undergoing primary robot-assisted RPLND between 2014 and 2019 in five institutions by eight urologists experienced in testis cancer and robotic surgery. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Variables such as demographic and clinicopathologic information, operative parameters and complication rates, oncologic outcomes, sexual recovery, and hospital length of stay were collected. Descriptive statistics are presented. RESULTS AND LIMITATIONS Forty-nine patients were analyzed with a median follow-up of 15.0 mo (interquartile range 6.5-29.1 mo). Median operative time was 288 min, estimated blood loss was 100 ml, and lymph node yield was 32. Median length of stay was 1 d. There were nine postoperative complications, 44% (4/9) of which were Clavien grade 1. There were no Clavien grade IV complications. Twenty-one patients had metastatic NSGCT (42.8%), of whom nine (18.4%) received adjuvant chemotherapy. Four patients experienced recurrence (three out-of-field and one in-field recurrence). Limitations include the retrospective study design and various surgical techniques among surgeons. CONCLUSIONS Primary robot-assisted RPLND for NSGCT can be performed safely, with low complication rates and acceptable oncologic outcomes reducing the need for chemotherapy. For a population in which compliance with surveillance is typically challenging, robot-assisted RPLND may improve quality of care and outcomes for patients with NSGCT. PATIENT SUMMARY In experienced centers, robot-assisted retroperitoneal lymph node dissection can be performed safely with similar oncologic outcomes to an open approach, while providing an option that may reduce the need for chemotherapy.
Collapse
Affiliation(s)
| | | | | | - Andrew T Lenis
- University of California Los Angeles, Los Angeles, CA, USA
| | - Mark S Litwin
- University of California Los Angeles, Los Angeles, CA, USA
| | - Jacob Jipp
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Marc A Bjurlin
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hung-Jui Tan
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | |
Collapse
|
34
|
Dworsky JQ, Childers CP, Copeland T, Maggard-Gibbons M, Tan HJ, Saliba D, Russell MM. Geriatric Events among Older Adults Undergoing Nonelective Surgery are Associated with Poor Outcomes. Am Surg 2020. [DOI: 10.1177/000313481908501003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Older adults undergoing nonelective surgery are at risk for geriatric events (GEs: delirium, dehydration, falls/fractures, failure to thrive, and pressure ulcers), but the impact of GEs on postoperative outcomes is unclear. Using the 2013 to 2014 National Inpatient Sample, we analyzed nonelective hospital admissions for five common operations (laparoscopic cholecystectomy, colectomy, soft tissue debridement, small bowel resection, and laparoscopic appendectomy) in older adults (aged ≥65 years) and a younger referent group (aged 55–64 years). Nationally weighted descriptive statistics were generated for GEs. Logistic regression controlling for patient, procedure, and hospital characteristics estimated the association of 1) age with GEs and 2) GEs with outcomes. Of 471,325 overall admissions, 64.7 per cent were aged ≥65 years. The rate of any GE in older adults was 26.9 per cent; GEs varied by age and procedure ( P < 0.001). After adjustment, the probability of any GE increased with age category ( P < 0.001); having any GE was associated with higher probability of all outcomes ( P < 0.001): mortality (4.5% vs 0.8%), postoperative complications (61.7% vs 24.9%), prolonged length of stay (24.3% vs 7.9%), and skilled nursing facility discharge (46.6% vs 10.3%). In addition, there was a dose–response relationship between GEs and negative outcomes. GEs are prevalent in the nonelective surgery setting and associated with worse clinical outcomes. Quality improvement efforts should focus on addressing GEs.
Collapse
Affiliation(s)
- Jill Q. Dworsky
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
| | - Christopher P. Childers
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
| | - Timothy Copeland
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
| | | | - Hung-Jui Tan
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Debra Saliba
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
- UCLA/JH Borun Center for Gerontological Research, Los Angeles, California
- RAND Corporation, Santa Monica, California
| | - Marcia M. Russell
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California
| |
Collapse
|
35
|
Tan TL, Tan HJ, Cheah CF, Kumaresh R, Azzahra NA. Silent microaspirations: The forerunner to the diagnosis of bulbar onset myasthenia gravis in a young woman. Med J Malaysia 2020; 75:295-297. [PMID: 32467548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Recurrent pneumonia warrants a diligent work-up to identify the underlying cause that perpetuates the disease process. Insidious bulbar dysfunction is arguably the most devastating as it would be diagnosed late after significant pulmonary complications due to chronic micro-aspiration. Bulbar disorder should be considered as the potential aetiology of recurrent pulmonary infections in the young population after excluding immunodeficiency disorder and respiratory anatomical anomaly. This report illustrates a rare case of bulbar onset myasthenia gravis which manifested as focal bronchiolectasis due to recurrent undiagnosed aspiration pneumonia three years earlier. Absence of hallmark features of Myasthenia Gravis (MG) such as ptosis, opthalmoplegia and proximal muscle weakness contributed to the diagnostic delay and challenges in this case. The diagnosis was established with the collaboration of multidisciplinary teams. Subsequent correct therapeutic interventions resulted in remarkable recovery in functional status and prevented her from further aspiration in the long run.
Collapse
Affiliation(s)
- T L Tan
- Hospital Seri Manjung, Department of Internal Medicine, Perak, Malaysia.
| | - H J Tan
- Hospital Seri Manjung, Department of Internal Medicine, Perak, Malaysia
| | - C F Cheah
- Hospital Raja Permaisuri Bainun, Neurology Unit, Perak, Malaysia
| | - R Kumaresh
- Hospital Raja Permaisuri Bainun, Department of Respiratory Medicine, Perak, Malaysia
| | - N A Azzahra
- Hospital Raja Permaisuri Bainun, Department of Radiology, Perak, Malaysia
| |
Collapse
|
36
|
Tan HJ. EDITORIAL COMMENT. Urology 2020; 138:44. [DOI: 10.1016/j.urology.2019.11.054] [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: 08/18/2019] [Accepted: 11/26/2019] [Indexed: 11/25/2022]
|
37
|
Abstract
INTRODUCTION To evaluate overall survival (OS) of T1a kidney cancers stratified by histologic subtype and curative treatment including partial nephrectomy (PN), percutaneous ablation (PA), and radical nephrectomy (RN). MATERIALS AND METHODS We queried the National Cancer Data Base (2004-2015) for patients with T1a kidney cancers who were treated surgically. OS was estimated by Kaplan-Meier curves based on histologic subtype and management. Cox proportional regression models were used to determine whether histologic subtypes and management procedure predicted OS. RESULTS 46,014 T1a kidney cancers met inclusion criteria. Kaplan Meier curves demonstrated differences in OS by treatment for clear cell, papillary, chromophobe, and cystic histologic subtypes (all p < 0.001), but no differences for sarcomatoid (p = 0.110) or collecting duct (p = 0.392) were observed. Adjusted Cox regression showed worse OS for PA than PN among patients with clear cell (HR 1.58, 95%CI [1.44-1.73], papillary RCC (1.53 [1.34-1.75]), and chromophobe RCC (2.19 [1.64-2.91]). OS was worse for RN than PN for clear cell (HR 1.38 [1.28-1.50]) papillary (1.34 [1.16-1.56]) and chromophobe RCC (1.92 [1.43-2.58]). Predictive models using Cox proportional hazards incorporating histology and surgical procedure alone were limited (c-index 0.63) while adding demographics demonstrated fair predictive power for OS (c-index 0.73). CONCLUSIONS In patients with pathologic T1a RCC, patterns of OS differed by surgery and histologic subtype. Patients receiving PN appears to have better prognosis than both PA and RN. However, the incorporation of histologic subtype and treatment modality into a risk stratification model to predict OS had limited utility compared with variables representing competing risks.
Collapse
Affiliation(s)
- Michael Siev
- Department of Urology, Division of Urologic Oncology, NYU Langone Health, New York, NY, USA
| | - Audrey Renson
- Department of Clinical Research, NYU Langone Hospital – Brooklyn, Brooklyn, NY, USA
| | - Hung-Jui Tan
- Department of Urology, Lineberger Comprehensive Cancer Center, Multidisciplinary Genitourinary Oncology, University of North Carolina, Chapel Hill, NC, USA
| | - Tracy L. Rose
- Department of Hematology/Oncology, Lineberger Comprehensive Cancer Center, Multidisciplinary Genitourinary Oncology, University of North Carolina, Chapel Hill, NC, USA
| | - Stella K. Kang
- Department of Radiology, NYU Langone Health, New York, NY, USA
- Department of Population Health, NYU Langone Health, New York, NY, USA
| | - William C. Huang
- Department of Urology, Division of Urologic Oncology, NYU Langone Health, New York, NY, USA
| | - Marc A. Bjurlin
- Department of Urology, Lineberger Comprehensive Cancer Center, Multidisciplinary Genitourinary Oncology, University of North Carolina, Chapel Hill, NC, USA
| |
Collapse
|
38
|
Chang EH, Tan HJ, Nielsen M. Management of small renal masses in patients with chronic kidney disease: Perspectives from a nephrologist. Urol Oncol 2019; 38:533-536. [PMID: 31889616 DOI: 10.1016/j.urolonc.2019.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/04/2019] [Accepted: 11/08/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Emily H Chang
- Division of Nephrology, UNC Kidney Center, Chapel Hill, NC.
| | - Hung-Jui Tan
- Department of Urology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew Nielsen
- Department of Urology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| |
Collapse
|
39
|
Filippou P, Mahajan S, Deal A, Wallen EM, Tan HJ, Pruthi RS, Smith AB. The Presence of Gender Bias in Letters of Recommendations Written for Urology Residency Applicants. Urology 2019; 134:56-61. [DOI: 10.1016/j.urology.2019.05.065] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 05/10/2019] [Accepted: 05/16/2019] [Indexed: 11/16/2022]
|
40
|
Smith AB, Mueller D, Garren B, Tan HJ, Wallen E, Woods M, Pruthi R, Nielsen M. Using qualitative research to reduce readmissions and optimize perioperative cystectomy care. Cancer 2019; 125:3545-3553. [PMID: 31299091 DOI: 10.1002/cncr.32362] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 02/26/2019] [Accepted: 03/23/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND Preventable complications and readmissions after cystectomy may be detectable via postoperative monitoring of patient-reported outcomes (PROs). However, no study has defined meaningful PROs or the use of mobile communication devices (mobile health [mHealth]) to capture them. The objectives of this study were to determine which high-priority PROs influence patients' perioperative experience, what processes influence these outcomes, how patients and caregivers differ in their experiences, and how mHealth might be used to improve outcomes. METHODS Forty-five semistructured, in-depth interviews were conducted with readmitted cystectomy patients, caregivers, and providers with an interview guide that addressed perioperative education, symptoms, function, and the potential for mHealth interventions. Among 15 patients, 10 had an interviewed partner. A thematic analysis of interviews conducted with readmitted patients, caregivers, and providers was performed to examine processes that affected perioperative care and readmission and to determine how mHealth interventions might be implemented. RESULTS Readmitted patients and caregivers ranged in age from 33 to 78 years and were diverse in race and stage. The providers included a diverse representation of physicians, nurses, and other specialists. Cystectomy preoperative education was overwhelming and lacked personalization, and this contributed to a fundamental lack of knowledge regarding normal and abnormal symptoms after surgery. Three connecting themes were identified: 1) cystectomy education overload, 2) a need to define normal symptoms, and 3) education with incremental learning through mHealth. CONCLUSIONS A personalized mHealth intervention addressing themes of education overload, the definition of normality, and incremental learning could be realized through mHealth technology and provide the right information for the right patient at the right time.
Collapse
Affiliation(s)
- Angela B Smith
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Dana Mueller
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brandon Garren
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Hung-Jui Tan
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Eric Wallen
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael Woods
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Raj Pruthi
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matthew Nielsen
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| |
Collapse
|
41
|
Mohan CS, Rotter JS, Nielsen ME, Pruthi RS, Wallen EM, Tan HJ, Smith AB. Patient Experience and Clinical Outcomes in Urologic Cancers: A Surveillance, Epidemiology, and End Results and Consumer Assessment of Healthcare Providers and Systems Study. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.698] [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: 10/25/2022]
|
42
|
Hayon S, Deal A, Tan HJ, Namboodri B, Wood C, Pruthi R. Is the Relative Value of Operative Time Equal Across Surgical Specialties? J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.694] [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: 10/25/2022]
|
43
|
Dworsky JQ, Childers CP, Copeland T, Maggard-Gibbons M, Tan HJ, Saliba D, Russell MM. Geriatric Events Among Older Adults Undergoing Nonelective Surgery Are Associated with Poor Outcomes. Am Surg 2019; 85:1089-1093. [PMID: 31657300 PMCID: PMC8019520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Older adults undergoing nonelective surgery are at risk for geriatric events (GEs: delirium, dehydration, falls/fractures, failure to thrive, and pressure ulcers), but the impact of GEs on postoperative outcomes is unclear. Using the 2013 to 2014 National Inpatient Sample, we analyzed nonelective hospital admissions for five common operations (laparoscopic cholecystectomy, colectomy, soft tissue debridement, small bowel resection, and laparoscopic appendectomy) in older adults (aged ≥65 years) and a younger referent group (aged 55-64 years). Nationally weighted descriptive statistics were generated for GEs. Logistic regression controlling for patient, procedure, and hospital characteristics estimated the association of 1) age with GEs and 2) GEs with outcomes. Of 471,325 overall admissions, 64.7 per cent were aged ≥65 years. The rate of any GE in older adults was 26.9 per cent; GEs varied by age and procedure (P < 0.001). After adjustment, the probability of any GE increased with age category (P < 0.001); having any GE was associated with higher probability of all outcomes (P < 0.001): mortality (4.5% vs 0.8%), postoperative complications (61.7% vs 24.9%), prolonged length of stay (24.3% vs 7.9%), and skilled nursing facility discharge (46.6% vs 10.3%). In addition, there was a dose-response relationship between GEs and negative outcomes. GEs are prevalent in the nonelective surgery setting and associated with worse clinical outcomes. Quality improvement efforts should focus on addressing GEs.
Collapse
Affiliation(s)
- Jill Q. Dworsky
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Christopher P. Childers
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Timothy Copeland
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
| | | | - Hung-Jui Tan
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Debra Saliba
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA
- UCLA/JH Borun Center for Gerontological Research, Los Angeles, CA
- RAND Corporation, Santa Monica, CA
| | - Marcia M. Russell
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| |
Collapse
|
44
|
Mayer SE, Tan HJ, Peacock Hinton S, Sanoff HK, Stürmer T, Hester LL, Faurot KR, Jonsson Funk M, Lund JL. Comparison of Medicare Claims-based Proxy Measures of Poor Function and Associations With Treatment Receipt and Mortality in Older Colon Cancer Patients. Med Care 2019; 57:286-294. [PMID: 30789540 PMCID: PMC6417959 DOI: 10.1097/mlr.0000000000001073] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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] [Indexed: 01/07/2023]
Abstract
BACKGROUND Multiple claims-based proxy measures of poor function have been developed to address confounding in observational studies of drug effects in older adults. We evaluated agreement between these measures and their associations with treatment receipt and mortality in a cohort of older colon cancer patients. METHODS Medicare beneficiaries age 66+ diagnosed with stage II-III colon cancer were identified in the Surveillance, Epidemiology, and End Results-Medicare database (2004-2011). Poor function was operationalized by: (1) summing the total poor function indicators for each model; and (2) estimating predicted probabilities of poor function at diagnosis. Agreement was evaluated using Fleiss' κ and Spearman's correlation. Associations between proxy measures and: (1) laparoscopic versus open surgery; (2) chemotherapy versus none; (3) 5-fluorouracil (5FU)+oxaliplatin (FOLFOX) versus 5FU monotherapy; and (4) 1-year mortality were estimated using log-binomial regression, controlling for age, sex, stage, and comorbidity. Survival estimates were stratified by functional group, age, and comorbidity. RESULTS Among 29,687 eligible colon cancer patients, 67% were 75+ years and 45% had stage III disease. Concordance across the poor function indicator counts was moderate (κ: 0.64) and correlation of predicted probability measures varied (ρ: 0.21-0.74). Worse function was associated with lower chemotherapy and FOLFOX receipt, and higher 1-year mortality. Within age and comorbidity strata, poor function remained associated with mortality. CONCLUSIONS While agreement varied across the claims-based proxy measures, each demonstrated anticipated associations with treatment receipt and mortality independent of comorbidity. Claims-based comparative effectiveness studies in older populations should consider applying one of these models to improve confounding control.
Collapse
Affiliation(s)
- Sophie E Mayer
- Department of Epidemiology, Gillings School of Global Public Health
| | | | | | - Hanna K Sanoff
- Division of Hematology/Oncology, School of Medicine & Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health
| | | | - Keturah R Faurot
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Jennifer L Lund
- Department of Epidemiology, Gillings School of Global Public Health
| |
Collapse
|
45
|
Lum SG, Gendeh BS, Husain S, Gendeh HS, Ismail MR, Toh CJ, Izaham A, Tan HJ. Internal carotid artery injury during endonasal sinus surgery: our experience and review of the literature. ACTA ACUST UNITED AC 2019; 39:130-136. [PMID: 30745587 PMCID: PMC6522866 DOI: 10.14639/0392-100x-1312] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 07/17/2016] [Accepted: 10/05/2017] [Indexed: 11/23/2022]
Abstract
Iatrogenic internal carotid artery injury is a catastrophic but uncommon complication of endonasal sinus surgery. We present our experience in managing this emergency situation. A 52-year-old man underwent revision endoscopic repair of recurrent cerebrospinal fluid leak that was complicated with profuse haemorrhage during removal of the anterior wall of sphenoid sinus using a Hajek sphenoid punch forceps. Immediate packing of the sphenoid sinus controlled the haemorrhage. Urgent angiography revealed injury at the paraclival segment of the left internal carotid artery. An endovascular stent was initially placed but thrombosed; it was subsequently converted to coil embolisation. The patient had watershed cerebral infarct with hemiparesis post procedure but made full recovery within 6 weeks. Immediate nasal packing followed by urgent angiography and endovascular stent placement is the least invasive definitive treatment. If stenting is unsuccessful, endovascular balloon occlusion or coil embolisation is the next preferred treatment, if there is adequate cross-cerebral circulation. The success of treatment relies on its immediate management by a multidisciplinary team.
Collapse
Affiliation(s)
- S G Lum
- Department of Otorhinolaryngology, Head and Neck Surgery, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia
| | - B S Gendeh
- Department of Otorhinolaryngology, Head and Neck Surgery, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia
| | - S Husain
- Department of Otorhinolaryngology, Head and Neck Surgery, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia
| | - H S Gendeh
- Department of Otorhinolaryngology, Head and Neck Surgery, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia
| | - M R Ismail
- Department of Radiology, UKMMC, Kuala Lumpur, Malaysia
| | - C J Toh
- Neurosurgery Unit, Department of Surgery, UKMMC, Kuala Lumpur, Malaysia
| | - A Izaham
- Department of Anaesthesiology, UKMMC, Kuala Lumpur, Malaysia
| | - H J Tan
- Neurology Unit, Department of Medicine, UKMMC, Kuala Lumpur, Malaysia
| |
Collapse
|
46
|
Abu-Salha YM, Wood CM, Hacker KE, Garren B, Filippou PL, Nielsen ME, Smith AB, Tan HJ, Pruthi RS. Scrutinizing Medicare Payments to the Highest Paid Urologists Using the Centers for Medicare and Medicaid Services Public Use Dataset. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.585] [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]
|
47
|
Graves JL, Lomboy JR, Hacker KE, Garren B, Wood CM, North AC, McKenna PH, Tan HJ, Pruthi RS. Impact of Surgeon Age on Surgical Practice Patterns: Potential Implications of an Aging Workforce. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.662] [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: 11/29/2022]
|
48
|
Lomboy JR, Graves JL, Smith AB, Nielsen ME, Wallen EM, Raynor MC, Tan HJ, Pruthi R. Impact of Surgeon Age on Preference for Open vs Laparoscopic/Robotic Partial and Radical Nephrectomy: Potential Implications of an Aging Workforce. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.578] [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]
|
49
|
Tan HJ, Chung A, Gotz D, Smith A, Wallen E, Pruthi R, Nielsen M. MP02-08 DISPARATE ACCESS TO ELECTRONIC HEALTH RECORDS AND QUALITY REPORTING AMONG US UROLOGISTS. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
50
|
Casilla-Lennon MM, Choi SK, Deal AM, Bensen JT, Narang G, Filippou P, McCormick B, Pruthi R, Wallen E, Tan HJ, Woods M, Nielsen M, Smith A. Financial Toxicity among Patients with Bladder Cancer: Reasons for Delay in Care and Effect on Quality of Life. J Urol 2017; 199:1166-1173. [PMID: 29155338 DOI: 10.1016/j.juro.2017.10.049] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Costly surveillance and treatment of bladder cancer can lead to financial toxicity, a treatment related financial burden. Our objective was to define the prevalence of financial toxicity among patients with bladder cancer and identify delays in care and its effect on health related quality of life. MATERIALS AND METHODS We identified patients with bladder cancer in the University of North Carolina Health Registry/Cancer Survivorship Cohort. Financial toxicity was defined as agreement with having "to pay more for medical care than you can afford." Health related quality of life was measured using general and cancer specific validated questionnaires. Statistical analyses were performed using the Fisher exact test and the Student t-test. RESULTS A total of 138 patients with bladder cancer were evaluated. Median age was 66.9 years, 75% of the patients were male and 89% were white. Of the participants 33 (24%) endorsed financial toxicity. Participants who were younger (p = 0.02), black (p = 0.01), reported less than a college degree (p = 0.01) and had noninvasive disease (p = 0.04) were more likely to report financial toxicity. On multivariable analysis only age was a significant predictor of financial toxicity. Patients who endorsed financial toxicity were more likely to report delaying care (39% vs 23%, p = 0.07) due to the inability to take time off work or afford general expenses. On general health related quality of life questionnaires patients with financial toxicity reported worse physical and mental health (p = 0.03 and <0.01, respectively), and lower cancer specific health related quality of life (p = 0.01), physical well-being (p = 0.01) and functional well-being (p = 0.05). CONCLUSIONS Financial toxicity is a major concern among patients with bladder cancer. Younger patients were more likely to experience financial toxicity. Those who endorsed financial toxicity experienced delays in care and poorer health related quality of life, suggesting that treatment costs should have an important role in medical decision making.
Collapse
Affiliation(s)
- Marianne M Casilla-Lennon
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Seul Ki Choi
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jeannette T Bensen
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Gopal Narang
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Pauline Filippou
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Benjamin McCormick
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Raj Pruthi
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Eric Wallen
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Hung-Jui Tan
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael Woods
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matthew Nielsen
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Angela Smith
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| |
Collapse
|