Development and Implementation of a Continuing Medical Education Program in Canada: Knowledge Translation for Renal Cell Carcinoma (KT4RCC)

An in-person multidisciplinary continuing medical education (CME) program was designed to address previously identified knowledge gaps regarding quality indicators of care in kidney cancer. The objective of this study was to develop a CME program and determine if the program was effective for improving participant knowledge. CME programs for clinicians were delivered by local experts (uro-oncologist and medical oncologist) in four Canadian cities. Participants completed knowledge assessment tests pre-CME, immediately post-CME, and 3-month post-CME. Test questions were related to topics covered in the CME program including prognostic factors for advanced disease, surgery for advanced disease, indications for hereditary screening, systemic therapy, and management of small renal masses. Fifty-two participants attended the CME program and completed the pre- and immediate post-CME tests. Participants attended in Ottawa (14; 27%), Toronto (13; 25%), Québec City (18; 35%), and Montréal (7; 13%) and were staff urologists (21; 40%), staff medical oncologists (9; 17%), fellows (5; 10%), residents (16; 31%), and oncology nurses (1; 2%). The mean pre-CME test score was 61% and the mean post-CME test score was 70% (p = 0.003). Twenty-one participants (40%) completed the 3-month post-CME test. Of those that completed the post-test, scores remained 10% higher than the pre-test (p value 0.01). Variability in test scores was observed across sites and between French and English test versions. Urologists had the largest specialty-specific increase in knowledge at 13.8% (SD 24.2, p value 0.02). The kidney cancer CME program was moderately effective in improving provider knowledge regarding quality indicators of kidney cancer care. These findings support continued use of this CME program at other sites.

The effect of surgery report cards on improving radical prostatectomy quality: the SuRep study protocol

Background

The goal of radical prostatectomy is to achieve the optimal balance between complete cancer removal and preserving a patient’s urinary and sexual function. Performing a wider excision of peri-prostatic tissue helps achieve negative surgical margins, but can compromise urinary and sexual function. Alternatively, sparing peri-prostatic tissue to maintain functional outcomes may result in an increased risk of cancer recurrence. The objective of this study is to determine the effect of providing surgeons with detailed information about their patient outcomes through a surgical report card.

Methods

We propose a prospective cohort quasi-experimental study. The intervention is the provision of feedback to prostate cancer surgeons via surgical report cards. These report cards will be distributed every 3 months by email and will present surgeons with detailed information, including urinary function, erectile function, and surgical margin outcomes of their patients compared to patients treated by other de-identified surgeons in the study. For the first 12 months of the study, pre-operative, 6-month, and 12-month patient data will be collected but there will be no report cards distributed to surgeons. This will form the pre-feedback cohort. After the pre-feedback cohort has completed accrual, surgeons will receive quarterly report cards. Patients treated after the provision of report cards will comprise the post-feedback cohort. The primary comparison will be post-operative function of the pre-feedback cohort vs. post-feedback cohort. The secondary comparison will be the proportion of patients with positive surgical margins in the two cohorts. Outcomes will be stratified or case-mix adjusted, as appropriate. Assuming a baseline potency of 20% and a baseline continence of 70%, 292 patients will be required for 80% power at an alpha of 5% to detect a 10% improvement in functional outcomes. Assuming 30% of patients may be lost to follow-up, a minimum sample size of 210 patients is required in the pre-feedback cohort and 210 patients in the post-feedback cohort.

Discussion

The findings from this study will have an immediate impact on surgeon self-evaluation and we hypothesize surgical report cards will result in improved overall outcomes of men treated with radical prostatectomy.

Electronic supplementary material

The online version of this article (10.1186/s12894-018-0403-y) contains supplementary material, which is available to authorized users.

Tranexamic Acid versus Placebo to Prevent Blood Transfusion during Radical Cystectomy for Bladder Cancer (TACT): Study Protocol for a Randomized Controlled Trial

BACKGROUND

Radical cystectomy for bladder cancer is associated with a high risk of needing red blood cell transfusion. Tranexamic acid reduces blood loss during cardiac and orthopedic surgery, but no study has yet evaluated tranexamic acid use during cystectomy.

METHODS

A randomized, double-blind (surgeon-, anesthesiologist-, patient-, data-monitor-blinded), placebo-controlled trial of tranexamic acid during cystectomy was initiated in June 2013. Prior to incision, the intervention arm participants receive a 10 mg/kg loading dose of intravenously administered tranexamic acid, followed by a 5 mg/kg/h maintenance infusion. In the control arm, the patient receives an identical volume of normal saline that is indistinguishable from the intervention. The primary outcome is any blood transfusion from the start of surgery up to 30 days post operative. There are no strict criteria to mandate the transfusion of blood products. The decision to transfuse is entirely at the discretion of the treating physicians who are blinded to patient allocation. Physicians are allowed to utilize all resources to make transfusion decisions, including serum hemoglobin concentration and vital signs. To date, 147 patients of a planned 354 have been randomized to the study.

DISCUSSION

This protocol reviews pertinent data relating to blood transfusion during radical cystectomy, highlighting the need to identify methods for reducing blood loss and preventing transfusion in patients receiving radical cystectomy. It explains the clinical rationale for using tranexamic acid to reduce blood loss during cystectomy, and outlines the study methods of our ongoing randomized controlled trial.

TRIAL REGISTRATIONS

Canadian Institute for Health Research (CIHR) Protocol: MOP-342559; ClinicalTrials.gov, ID: NCT01869413. Registered on 5 June 2013.

An assessment of Prostate Cancer Research International: Active Surveillance (PRIAS) criteria for active surveillance of clinically low-risk prostate cancer patients

INTRODUCTION

Active surveillance is a strategy to delay or prevent treatment of indolent prostate cancer. The Prostate Cancer Research International: Active Surveillance (PRIAS) criteria were developed to select patients for prostate cancer active surveillance. The objective of this study was to compare pathological findings from PRIAS-eligible and PRIAS-ineligible clinically low-risk prostate cancer patients.

METHODS

A D'Amico low-risk cohort of 1512 radical prostatectomy patients treated at The Ottawa Hospital or Memorial Sloan Kettering Cancer Centre between January 1995 and December 2007 was reviewed. Pathological outcomes (pT3 tumours, Gleason sum ≥7, lymph node metastases, or a composite) and clinical outcomes (prostate-specific antigen [PSA] recurrence, secondary cancer treatments, and death) were compared between PRIAS-eligible and PRIAS-ineligible cohorts.

RESULTS

The PRIAS-eligible cohort (n=945) was less likely to have Gleason score ≥7 (odds ratio [OR] 0.61; 95% confidence interval [CI] 0.49-0.75), pT3 (OR 0.41; 95% CI 0.31-0.55), nodal metastases (OR 0.37; 95% CI 0.10-1.31), or any adverse feature (OR 0.56; 95% CI 0.45-0.69) compared to the PRIAS-ineligible cohort. The probability of any adverse pathology in the PRIAS-eligible cohort was 41% vs. 56% in the PRIAS-ineligible cohort. At median follow-up of 3.7 years, 72 (4.8%) patients had a PSA recurrence, 24 (1.6%) received pelvic radiation, and 13 (0.9%) received androgen deprivation. No difference was detected for recurrence-free and overall survival between groups (recurrence hazard ratio [HR] 0.71; 95% CI 0.46-1.09 and survival HR 0.72; 95% CI 0.36-1.47).

CONCLUSIONS

Low-risk prostate cancer patients who met PRIAS eligibility criteria are less likely to have higher-risk cancer compared to those who did not meet at least one of these criteria.

Needs Assessment Survey for the Management of Kidney Cancer

INTRODUCTION

In this study we determined self-perceived knowledge gaps and continuing medical education preferences among Canadian urologists and medical oncologists related to the treatment of patients with kidney cancer.

METHODS

A needs assessment survey was created by the Quality Initiative group of the Kidney Cancer Research Network of Canada using an iterative feedback process. The survey determined knowledge gaps and continuing medical education preferences pertaining to 23 previously validated quality indicators of kidney cancer care. Topics included screening, diagnosis, prognosis, surgical management, systemic therapies and followup care. The survey was distributed via e-mail to Canadian urologists and medical oncologists.

RESULTS

Among the 164 respondents 121 (74%) were urologists and 43 (26%) were medical oncologists. The majority of respondents practice in academic (72, 57%) or large urban community centers (40, 32%). Of the 23 quality indicators examined 14 were designated as priority continuing medical education topics based on perceived inadequate knowledge or high interest in the topic. Priority topics were similar for urologists and medical oncologists, and covered the spectrum of kidney cancer care with an emphasis on hereditary kidney cancer and management of advanced disease. Most respondents preferred that continuing medical education be delivered through in person, case based group discussions.

CONCLUSIONS

Canadian urologists and medical oncologists report similar knowledge gaps and continuing medical education preferences regarding kidney cancer care. Priority topics include screening for hereditary kidney cancer and management of advanced disease.

Prostate volume estimations using magnetic resonance imaging and transrectal ultrasound compared to radical prostatectomy specimens

INTRODUCTION

We sought to evaluate the accuracy of prostate volume estimates in patients who received both a preoperative transrectal ultrasound (TRUS) and magnetic resonance imaging (MRI) in relation to the referent pathological specimen post-radical prostatectomy.

METHODS

Patients receiving both TRUS and MRI prior to radical prostatectomy at one academic institution were retrospectively analyzed. TRUS and MRI volumes were estimated using the prolate ellipsoid formula. TRUS volumes were collected from sonography reports. MRI volumes were estimated by two blinded raters and the mean of the two was used for analyses. Pathological volume was calculated using a standard fluid displacement method.

RESULTS

Three hundred and eighteen (318) patients were included in the analysis. MRI was slightly more accurate than TRUS based on interclass correlation (0.83 vs. 0.74) and absolute risk bias (higher proportion of estimates within 5, 10, and 20 cc of pathological volume). For TRUS, 87 of 298 (29.2%) prostates without median lobes differed by >10 cc of specimen volume and 22 of 298 (7.4%) differed by >20 cc. For MRI, 68 of 298 (22.8%) prostates without median lobes differed by >10 cc of specimen volume, while only 4 of 298 (1.3%) differed by >20 cc.

CONCLUSIONS

MRI and TRUS prostate volume estimates are consistent with pathological volumes along the prostate size spectrum. MRI demonstrated better correlation with prostatectomy specimen volume in most patients and may be better suited in cases where TRUS and MRI estimates are disparate. Validation of these findings with prospective, standardized ultrasound techniques would be helpful.

Laparoscopic nephroureterectomy is associated with higher risk of adverse events compared to laparoscopic radical nephrectomy

INTRODUCTION

Laparoscopic radical nephrectomy (LRN) and laparoscopic nephroureterectomy (LNU) are similar procedures and some surgeons may believe the perioperative risks are the same. The purpose of this study is to characterize and compare complications following LRN and LNU.

METHODS

A historical cohort of patients who received either LRN or LNU between 2006 and 2012 was reviewed from the National Surgical Quality Improvement Program (NSQIP) database. Patient characteristics, surgical characteristics, and perioperative outcomes up to 30 days postoperatively were abstracted. Unadjusted and adjusted associations between procedure (LRN or LNU) and any adverse event were determined.

RESULTS

During the study period, 4904 patients met study inclusion criteria; 4159 (84.8%) received a LRN while 745 (15.2%) received a LNU. Overall, 651 (13.3%) patients experienced at least one postoperative complication. LNU was associated with more complications than LRN (21% and 12%, respectively, p value <0.01). The most common complications were: bleeding requiring blood transfusion (9.0% LNU vs. 6.0% LRN), urinary tract infection (4.6% LNU vs. 1.5% LRN), wound infection (1.3% LNU vs. 1.8% LRN), and unplanned intubation (2.3% LNU vs. 0.9% LRN). After adjusting for potential confounders, LNU was associated with higher risk of any complication compared to LRN (relative risk [RR] 1.41, 95% confidence interval [CI] 1.16-1.72). Other variables independently associated with an increased risk of complications included: increasing patient age (RR 1.01, 95% CI 1.01-1.02), American Society of Anesthesiologists (ASA) classification ≥3 (RR 1.34, 95% CI 1.10-1.63), higher preoperative creatinine (RR 1.11, 95% CI 1.06-1.17), >4 units of blood transfused within 72 hours before surgery (RR 1.93, 95% CI 1.29-2.86), and operative time >6 hours (RR 2.17, 95% CI 1.71-2.75).

CONCLUSIONS

Postoperative complications within 30 days of surgery are common after LNU and LRN. Despite having technical similarities, LNU carries a significantly higher risk of developing short-term complications compared to LRN. This information should be considered when counseling patients prior to surgery. Notable limitations of this study included the lack of information on tumour stage and management of the distal ureter.

Change in Adverse Events After Enrollment in the National Surgical Quality Improvement Program: A Systematic Review and Meta-Analysis

Background

The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) is the first nationally validated, risk-adjusted, outcomes-based program to measure and compare the quality of surgical care across North America. Participation in this program may provide an opportunity to reduce the incidence of adverse events related to surgery.

Study Design

A systematic review of the literature was performed. MedLine, EMBASE and PubMed were searched for studies relevant to NSQIP. Patient characteristics, intervention, and primary outcome measures were abstracted. The intervention was participation in NSQIP and monitoring of Individual Site Summary Reports with or without implementation of a quality improvement program. The outcomes of interest were change in peri-operative adverse events and mortality represented by pooled risk ratios (pRR) and 95% confidence intervals (CI).

Results

Eleven articles reporting on 35 health care institutions were included. Nine (82%) of the eleven studies implemented a quality improvement program. Minimal improvements in superficial (pRR 0.81; 95% CI 0.72–0.91), deep (pRR 0.82; 95% CI0.64–1.05) and organ space (pRR 1.15; 95% CI 0.96–1.37) infections were observed at centers that did not institute a quality improvement program. However, centers that reported formal interventions for the prevention and treatment of infections observed substantial improvements (superficial pRR 0.55, 95% CI 0.39–0.77; deep pRR 0.61, 95% CI 0.50–0.75, and organ space pRR 0.60, 95% CI 0.50–0.71). Studies evaluating other adverse events noted decreased incidence following NSQIP participation and implementation of a formal quality improvement program.

Conclusions

These data suggest that NSQIP is effective in reducing surgical morbidity. Improvement in surgical quality appears to be more marked at centers that implemented a formal quality improvement program directed at the reduction of specific morbidities.

Reducing the Harm of Prostate Cancer Screening: Repeated Prostate-Specific Antigen Testing

OBJECTIVE

To determine if repeating a prostate-specific antigen (PSA) test in men with an elevated PSA level is associated with a decreased risk of prostate biopsy and cancer diagnosis.

PATIENTS AND METHODS

A cohort of patients referred to the Ottawa Regional Prostate Cancer Assessment Clinic from April 1, 2008, through May 31, 2013, who had referral PSA levels between 4 and 10 ng/mL were included in the study. Univariate and multivariate associations between a normal result on repeated PSA testing and the risk of prostate biopsy, cancer diagnosis, and Gleason score of 7 or higher were examined.

RESULTS

The study cohort included 1268 patients. Repeated PSA test results were normal in 315 patients (24.8%). Men with normal results on repeated PSA testing were younger (mean ± SD age, 61.5±8.2 years vs 65.2±8.2 years; P<.001) and had lower referral PSA levels (mean ± SD, 5.5±1.4 ng/mL vs 6.6±1.5 ng/mL; P<.001) than men with an abnormal repeated PSA result. In multivariate analysis, men with normal results on repeated PSA testing were less likely to undergo prostate biopsy (relative risk [RR], 0.42; 95% CI, 0.34-0.50) and were at lower risk for cancer diagnosis (RR, 0.22; 95% CI, 0.14-0.34) and Gleason score of 7 or higher (RR, 0.16; 95% CI, 0.08-0.34) compared with men who had an abnormal repeated PSA test result.

CONCLUSION

Routinely repeating a PSA test in patients with an elevated PSA level is independently associated with decreased risk of prostate biopsy and prostate cancer diagnosis. Men with an elevated PSA level should be given a repeated PSA test before proceeding to biopsy.

The association between renal tumour scoring system components and complications of partial nephrectomy

INTRODUCTION

We evaluate the associations between 3 renal tumour scoring systems and their components with perioperative complications of partial nephrectomy.

METHODS

A consecutive cohort of partial nephrectomy patients was analyzed. Patient characteristics were abstracted from medical records. PADUA scores (preoperative aspects and dimensions used for anatomic classification), RENAL (radius exophyic/endophytic nearness anterior/posterior location scoring) nephrometry scores, and Centrality index (C-index) were determined from preoperative axial images by 2 independent reviewers. Cases were evaluated for postoperative complications up to 30 days after surgery. Pre-specified complication definitions were used for 33 potential medical and surgical complications. Unadjusted and adjusted associations between overall scores, individual components, and complications were determined using log binomial regression.

RESULTS

In total, 118 patients were included in the study. Of these, 36 (30.5%) surgical complications occurred in 27 (22.9%) patients. Fourteen (11.9%) were Clavien grade ≥3. Overall PADUA score was significantly associated with surgical and overall complications after adjusting for potential confounders. Among all components of the 3 scoring systems, only tumour diameter and exophytic/endophytic nature of the tumour were significantly associated with complications after adjusting for the other components of the respective scoring system (p < 0.05).

CONCLUSIONS

Renal tumour scoring systems may help predict the risk of complications after partial nephrectomy. Further refinement of current systems is required. A first step would be to include only components that are significantly associated with complications.

Predicting the Gleason sum of a patient with a prostate biopsy core Gleason ≤7 and a prostate biopsy core Gleason ≥8

INTRODUCTION

We review a subset of men who had discordant prostate biopsy sums and were treated with radical prostatectomy.

METHODS

Consecutive patients treated with radical prostatectomy at The Ottawa Hospital between 2000 and 2012 were reviewed. Those with at least 1 prostate biopsy core of Gleason sum ≥8 and at least 1 prostate biopsy core of Gleason sum ≤7 cancer were included.

RESULTS

Of the 764 radical prostatectomies, 661 (87%) were eligible for the study and 35 (5%) met inclusion criteria. Of these, only 16 (46%) had prostatectomy Gleason sum of ≥8. When the highest biopsy core was Gleason sum 8 (n = 24), only 7 (29%) had a prostatectomy Gleason sum ≥8. When the highest biopsy core was Gleason 9 (n = 11), 9 (82%) had a prostatectomy Gleason sum ≥8 (relative risk [RR] 2.8; p = 0.004). Patients with clinical T3 tumours were at higher risk of Gleason sum ≥8 compared to cT1 patients (RR 3.7; p = 0.008). Patient age (p = 0.89), preoperative prostate-specific antigen (p = 0.34), prostate volume (p = 0.86), number of biopsy cores (p = 0.18), and proportion of biopsy cores with cancer (p = 0.96) were not strongly associated with risk of prostatectomy Gleason sum ≥8.

CONCLUSION

These data should be considered when assigning patients into prognostic risk categories based on prostate biopsy information. Further study to verify our findings using larger samples is warranted.

Radiotherapy after radical prostatectomy: treatment recommendations differ between urologists and radiation oncologists

Purpose

There is no consensus on optimal use of radiotherapy following radical prostatectomy. The purpose of this study was to describe opinions of urologists and radiation oncologists regarding adjuvant and salvage radiotherapy following radical prostatectomy.

Methods

Urologists and genitourinary radiation oncologists were solicited to participate in an online survey. Respondent characteristics included demographics, training, practice setting, patient volume/experience, and access to radiotherapy. Participant practice patterns and attitudes towards use of adjuvant and salvage radiotherapy in standardized clinical scenarios were assessed.

Results

One hundred and forty-six staff physicians participated in the survey (104 urologists and 42 genitourinary radiation oncologists). Overall, high Gleason score (Gleason 7 vs. 6, RR 1.37 95% CI 1.19-1.56, p<0.0001 and Gleason 8-10 vs. 6, RR 1.56 95% CI 1.37-1.78, p<0.0001), positive surgical margin (RR 1.43 95% CI 1.26-1.62, p<0.0001), and extraprostatic tumour extension (RR 1.16 95% CI 1.05-1.28, p<0.002) conferred an increased probability of recommending adjuvant radiotherapy. Radiation oncologists were more likely to recommend adjuvant radiotherapy across all clinical scenarios (RR 1.48, 95% CI 1.39, 1.60, p <0.001). Major differences were found for patients with Gleason 6 and isolated positive surgical margin (radiotherapy selected by 21% of urologists vs. 70% of radiation oncologists), and patients with extraprostatic extension and negative surgical margins (radiotherapy selected by 18% of urologist vs. 57% of radiation oncologists).

Conclusions

Urologists and radiation oncologists frequently disagree about recommendation for post-prostatectomy adjuvant radiotherapy. Since clinical equipoise exists between adjuvant versus early salvage post-operative radiotherapy, support of clinical trials comparing these approaches is strongly encouraged.

Blood transfusion and hemostatic agents used during radical cystectomy

BACKGROUND

Radical cystectomy may result in significant blood loss necessitating transfusion. The purpose of this study was to determine what intra-operative techniques and hemostatic agents are currently used by uro-oncologists to prevent and control blood loss during radical cystectomy.

METHODS

In August 2011, members of the Society of Urologic Oncology (SUO) were solicited to complete an online survey. Residents, fellows and non-urologists were excluded. Canadian members received a personal email invitation. Respondents were asked to provide demographic information and opinions regarding blood loss and transfusion. Participants were also asked to report techniques used to reduce blood loss.

RESULTS

Of the 34 Canadian SUO members with registered email addresses, 27 (79%) completed the survey and met inclusion criteria as staff urologists who perform radical cystectomy. In addition, 52 non-Canadian SUO members were included in the analysis. Among all SUO respondents, a high proportion (73; 88%) reported using topical hemostatic agents during cystectomy. Thirty-six (46%) surgeons reported occasionally using procedural techniques and 9 (11%) using systemic hemostatic agents. Number of years since training was associated with decreased use of topical agents and increased use of procedural techniques (p < 0.01). Number of cystectomies per year was associated with decreased use of topical hemostatic agents (p < 0.01).

INTERPRETATION

Based on a survey of practice, there is significant risk of blood loss requiring transfusion during radical cystectomy. Surgeons frequently use topical hemostatic agents and rarely use systemic drugs to prevent or control blood loss. Trials evaluating agents and techniques to reduce blood loss during radical cystectomy are needed.

Diagnostic tests in urology: magnetic resonance imaging (MRI) for the staging of prostate cancer

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The use of MRI for prostate cancer diagnosis and staging is increasing. Indications for prostate MRI are not defined and many clinicians are unsure of how best to use MRI to aid clinical decisions. This evidence-based medicine article addresses the clinical utility of prostate MRI for preoperative staging. Based on a common patient scenario, a guide to calculating the probability of extraprostatic extension is provided.

Diagnostic tests in urology: percentage of free prostate-specific antigen (PSA)

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Free to total PSA ratios are commonly used as an adjunct to total PSA levels to better define an individual's risk for prostate cancer; however, its strengths and weaknesses are not well understood. This article illustrates the use of likelihood ratios that can be generated from the reported sensitivities and specificities from given free to total PSA thresholds in either increasing or decreasing an individual patient's probability of prostate cancer. Understanding the strengths and limitations of free to total PSA testing will help clinicians anticipate whether its use is indicated or not.