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Ladi-Seyedian SS, Ghoreifi A, Konety B, Pohar K, Holzbeierlein JM, Taylor J, Kates M, Willard B, Taylor JM, Liao JC, Kaimakliotis HZ, Porten SP, Steinberg GD, Tyson MD, Lotan Y, Daneshmand S. Racial Differences in the Detection Rate of Bladder Cancer Using Blue Light Cystoscopy: Insights from a Multicenter Registry. Cancers (Basel) 2024; 16:1268. [PMID: 38610946 PMCID: PMC11011163 DOI: 10.3390/cancers16071268] [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: 03/06/2024] [Revised: 03/16/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
The use of blue light cystoscopy (BLC) has been shown to improve bladder tumor detection. However, data demonstrating the efficacy of BLC across different races are limited. Herein, we aim to evaluate heterogeneity in the characteristics of BLC for the detection of malignant lesions among various races. Clinicopathologic information was collected from patients enrolled in the multi-institutional Cysview® registry (2014-2021) who underwent transurethral resection or biopsy of bladder tumors. Outcome variables included sensitivity and negative and positive predictive values of BLC and white light cystoscopy (WLC) for the detection of malignant lesions among various races. Overall, 2379 separate lesions/tumors were identified from 1292 patients, of whom 1095 (85%) were Caucasian, 96 (7%) were African American, 51 (4%) were Asian, and 50 (4%) were Hispanic. The sensitivity of BLC was higher than that of WLC in the total cohort, as well as in the Caucasian and Asian subgroups. The addition of BLC to WLC increased the detection rate by 10% for any malignant lesion in the total cohort, with the greatest increase in Asian patients (18%). Additionally, the positive predictive value of BLC was highest in Asian patients (94%), while Hispanic patients had the highest negative predictive value (86%). Our study showed that regardless of race, BLC increases the detection of bladder cancer when combined with WLC.
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Affiliation(s)
- Seyedeh-Sanam Ladi-Seyedian
- Department of Urology, Norris Cancer Center, University of Southern California, Los Angeles, CA 90033, USA; (S.-S.L.-S.); (A.G.)
| | - Alireza Ghoreifi
- Department of Urology, Norris Cancer Center, University of Southern California, Los Angeles, CA 90033, USA; (S.-S.L.-S.); (A.G.)
| | | | - Kamal Pohar
- Department of Urology, Ohio State University, Columbus, OH 43210, USA;
| | | | - John Taylor
- Department of Urology, University of Kansas, Kansas City, KS 66045, USA; (J.M.H.); (J.T.)
| | - Max Kates
- The James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD 21224, USA;
| | | | - Jennifer M. Taylor
- Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Joseph C. Liao
- VA Palo Alto Health Care System, Palo Alto, CA 94304, USA;
| | | | - Sima P. Porten
- Department of Urology, University of California San Francisco, San Francisco, CA 94115, USA;
| | - Gary D. Steinberg
- Department of Urology, Allina Health Cancer Institute, University of Minnesota, Minneapolis, MN 55407, USA;
| | - Mark D. Tyson
- Department of Urology, Mayo Clinic Hospital, Phoenix, AZ 85054, USA;
| | - Yair Lotan
- UT Southwestern Medical Center, Dallas, TX 75390, USA;
| | - Siamak Daneshmand
- Department of Urology, Norris Cancer Center, University of Southern California, Los Angeles, CA 90033, USA; (S.-S.L.-S.); (A.G.)
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Myers A, Ristau B, Mossanen M, Tyson MD, Chisolm S, Sloan F, Ball CT, Smith A, Lyon TD. Patient reported treatment burden and attitudes towards in-home intravesical therapy among patients with bladder cancer. Urol Oncol 2024; 42:29.e17-29.e22. [PMID: 37993341 DOI: 10.1016/j.urolonc.2023.09.006] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/12/2023] [Indexed: 11/24/2023]
Abstract
PURPOSE To quantify patient reported treatment burden while receiving intravesical therapy for bladder cancer and to survey patient perspectives on in-home intravesical therapy. MATERIALS AND METHODS We conducted a cross-sectional survey of the Bladder Cancer Advocacy Network Patient Survey Network. Survey questions were developed by investigators, then iteratively revised by clinician and patient advocates. Eligible participants had to have received at least 1 dose of intravesical therapy delivered in an ambulatory setting. RESULTS Two hundred thirty-three patients responded to the survey with median age of 70 years (range 33-88 years). Two-thirds of respondents (66%, 151/232) had received greater than 12 bladder instillations. A travel time of >30 minutes to an intravesical treatment facility was reported by 55% (126/231) of respondents. Fifty-six percent (128/232) brought caregivers to their appointments, and 36% (82/230) missed work to receive treatment. Sixty-one respondents (26%) felt the process of receiving bladder instillations adversely affected their ability to perform regular daily activities. Among those surveyed, 72% (168/232) reported openness to receiving in-home intravesical instillations and 54% (122/228) answered that in-home instillations would make the treatment process less disruptive to their lives. CONCLUSIONS Bladder cancer patients reported considerable travel distances, time requirements, and need for caregiver support when receiving intravesical therapy. Nearly three-quarters of survey respondents reported openness to receiving intravesical instillations in their home, with many identifying potential benefits for home over clinic-based therapy.
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Affiliation(s)
- Amanda Myers
- Department of Urology, MD Anderson Cancer Center, Houston, TX
| | | | - Matthew Mossanen
- Division of Urologic Surgery, Brigham & Women's Hospital, Dana Farber Cancer Institute, Boston, MA
| | - Mark D Tyson
- Department of Urology, Mayo Clinic, Scottsdale, AZ
| | | | - Frank Sloan
- Department of Economics, Duke University, Durham, NC
| | - Colleen T Ball
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Jacksonville, FL
| | - Angela Smith
- Department of Urology, University of North Carolina, Chapel Hill, NC
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Tyson MD. Single incision robotic cystectomy and urinary diversion. World J Urol 2024; 42:45. [PMID: 38244073 DOI: 10.1007/s00345-023-04751-y] [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: 10/26/2023] [Accepted: 11/27/2023] [Indexed: 01/22/2024] Open
Abstract
PURPOSE In this review, we aim to provide readers with a balanced understanding of all aspects of single incision robotic cystectomy (SIRC) and urinary diversion using the single-port (SP) robot. The review will trace the historical progression from open surgery to the introduction of minimally invasive approaches and present an in-depth description of the SIRC technique, offering a step-by-step guide for reference. Emphasis will be placed on indications and patient selection criteria to equip surgeons with well-rounded insights for decision-making. METHODS The review analyzes preliminary surgical outcomes by drawing from existing literature and clinical experiences, endeavoring to present a balanced view of the potential benefits and limitations. Addressing the learning curve and training prerequisites is paramount, and this review explores strategies and challenges in preparing surgeons for proficiency. Finally, the focus shifts to current challenges and future directions, identifying key issues and potential advancements in the field. CONCLUSIONS By presenting historical context, technical insights, clinical evidence, and strategic foresight, the review aims to provide a comprehensive resource that engages surgeons, researchers, and trainees from diverse perspectives.
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Affiliation(s)
- Mark D Tyson
- Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ, 85054, USA.
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Tyson MD, Abouassaly R, Durant A, Smith AB, Seemann K, Shoskes DA. Reply by Authors. Urol Pract 2024; 11:60. [PMID: 38117970 DOI: 10.1097/upj.0000000000000489.02] [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] [Received: 08/28/2023] [Accepted: 10/21/2023] [Indexed: 12/22/2023]
Affiliation(s)
| | | | | | | | - Kim Seemann
- Coreva Scientific GmbH & Co.KG, Königswinter, North Rhine-Westphalia, Germany
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Tyson MD, Abouassaly R, Durant A, Smith AB, Seemann K, Shoskes DA. Budgetary Impact of Including the Urinary Genomic Marker Cxbladder Detect in the Evaluation of Microhematuria Patients. Urol Pract 2024; 11:54-60. [PMID: 37914255 DOI: 10.1097/upj.0000000000000489] [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: 08/28/2023] [Accepted: 10/21/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION Current AUA guidelines mandate a risk-stratified approach for the evaluation of microhematuria. Urine genomic tests with high negative predictive value could further reduce unnecessary diagnostic testing and morbidity, but the economic impact is unknown. This study modeled the financial impact of Cxbladder Detect on microhematuria evaluations. METHODS A decision tree analysis was constructed by Coreva Scientific comparing 1-year costs of the standard microhematuria evaluation using the AUA guidelines vs an algorithm incorporating Cxbladder Detect. Cxbladder Detect-positive patients had cystoscopy and imaging, whereas patients with negative tests were reevaluated in 6 months. Patients with positive diagnostic testing underwent cystoscopy, and positive cystoscopies led to transurethral resection of bladder tumor. Test performance was based on published literature, and costs were based on Medicare allowable fees. RESULTS Using the decision tree model, the average savings of using Cxbladder Detect was $559 compared with the standard of care, with an average reduction of 0.38 procedures per patient. Probabilistic analysis showed statistical significance with a median reduction in the total cost of $498 per patient (95% CrI [-1356, -2]) and a significant median reduction in diagnostic procedures per patient of 0.36 (95% CrI [-0.52, -0.16]) without impact on the number of cancers diagnosed. CONCLUSIONS This model-based study demonstrates the potential economic value of using a Cxbladder-driven protocol for microhematuria evaluations.
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Affiliation(s)
| | | | | | | | - Kim Seemann
- Coreva Scientific GmbH & Co.KG, Königswinter, North Rhine-Westphalia, Germany
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Durant AM, Choudry MM, Madura G, Mi L, Faraj KS, Tyson MD. Bacillus Calmette-Guerin (BCG) therapy is safe and effective in non-muscle invasive bladder cancer (NMIBC) patients with immunomodulating conditions. Urol Oncol 2024; 42:21.e21-21.e28. [PMID: 37852817 PMCID: PMC10842448 DOI: 10.1016/j.urolonc.2023.09.010] [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: 05/02/2023] [Revised: 08/18/2023] [Accepted: 09/19/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Bacillus Calmette-Guerin (BCG) is the most effective therapy available to treat high-risk nonmuscle invasive bladder cancer (NMIBC) patients. However, for patients with immunomodulating conditions BCG is a relative contraindication due to efficacy and safety concerns. To our knowledge, no population-level study evaluating the efficacy and safety profile of BCG for immunomodulated patients exists. METHODS NMIBC patients aged 66 years or older were identified in the Surveillance, Epidemiology, and End Results (SEER) - Medicare database from 1975-2013. All patients completed adequate BCG (at least 5 plus 2 treatments completed within 12 months of diagnosis). Two groups were defined: an immunomodulated population identified by immunomodulating conditions such as solid-organ transplantation, HIV, and autoimmune conditions, and an immunocompetent group. The primary endpoint was 5-year progression-free survival defined as progression to systemic chemotherapy, checkpoint inhibitors, radical or partial cystectomy, metastasis, or cancer-specific death. A safety analysis was performed as a secondary outcome. RESULTS In a total of 4,277 patients with NMIBC who completed adequate BCG, 606 (14.2%) were immunomodulated. The immunomodulated group was older at diagnosis (P < 0.001), more likely to be female (P < 0.001), more likely to live in a metropolitan area (P < 0.001), and had higher Charlson comorbidity scores (P < 0.001). There were no differences in progression to chemotherapy (P = 0.17), checkpoint inhibitors (P > 0.99), radical cystectomy (P = 0.40), partial cystectomy (P = 0.93), metastasis (P = 0.19), cancer-specific death (P = 0.18) or 5-year total bladder cancer progression (P = 0.30) between the groups. For the safety analysis, rates of disseminated BCG were similar between immunomodulated and immunocompetent patients (0.7% vs. <1.8%, P = 0.51). On multivariable analysis 5-year total bladder cancer progression (HR 1.07 [CI 0.88-1.30]) was similar between the groups. CONCLUSION Rates of bladder cancer progression and disseminated BCG complications 5-years after BCG therapy were similar regardless of immunomodulation status. These findings suggest that BCG intravesical therapy can be offered to immunomodulated patients with high-risk NMIBC although theoretical infectious complication risks remain.
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Affiliation(s)
- Adri M Durant
- Department of Urology, Mayo Clinic Arizona, Phoenix, AZ.
| | | | - Grace Madura
- Mayo Clinic College of Medicine and Science, Scottsdale, AZ
| | - Lanyu Mi
- Department of Quantitative Health Sciences, Mayo Clinic Arizona, Scottsdale, AZ
| | - Kassem S Faraj
- Department of Urology, University of Michigan, Ann Arbor, MI
| | - Mark D Tyson
- Department of Urology, Mayo Clinic Arizona, Phoenix, AZ
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Durant AM, Whitney MA, Chang YHH, Larson MA, Shah PH, Lyon TD, Humphreys MR, Etzioni DA, Tyson MD. Surgical Site Infections in Open and Laparoscopic Operations in Rooms With Open-floor Drainage Systems. Urol Pract 2023; 10:622-629. [PMID: 37498642 DOI: 10.1097/upj.0000000000000434] [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: 04/06/2023] [Accepted: 06/30/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Surgical site infections are common postoperative complications. Some operating rooms have open-floor drainage systems for fluid disposal during endourologic cases, although nonendoscopy cases are not always allowed in these rooms. We hypothesized that operating rooms with open-floor drainage systems would not materially affect risk of surgical site infections for patients undergoing open and laparoscopic procedures. METHODS Patients who had surgical site infections from 2016 through 2020 were identified from data of the National Surgical Quality Improvement Program. Patients without surgical incisions, with open wounds, and with surgical site infections at surgery were excluded. The primary outcome was surgical site infection occurrence within 30 days of surgery. Multilevel multivariable logistic regression was used to estimate the observed-to-expected surgical site infection ratio for each operating room (2 with and 23 without open-floor drainage systems). RESULTS We identified 8,419 surgical cases, of which 802 (9.5%) were performed in operating rooms with open-floor drainage systems; 166 patients (2.0%) had surgical site infections. Of the surgical site infections, 7 (4.2%) occurred in operating rooms with open-floor drainage systems. Surgical specialty, American Society of Anesthesiologists physical status, higher case acuity, dyspnea, immunosuppression, longer surgical duration, and wound classification were associated with surgical site infections (P < .05 for all). The observed-to-expected ratios of surgical site infections occurring in the 2 operating rooms with open-floor drainage systems were 0.85 and 1.15. The odds ratio of surgical site infections for urologic cases performed in room with vs without open-floor drainage systems was 1.30 (P = .65). CONCLUSIONS Urology operating room designs often include open-floor drainage systems for water-based cases. These drainage systems were not associated with an increased risk of surgical site infections.
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Affiliation(s)
- Adri M Durant
- Department of Urology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona
| | - Madeline A Whitney
- Student, Mayo Clinic Alix School of Medicine-Arizona campus, Mayo Clinic College of Medicine and Science, Scottsdale, Arizona
| | - Yu-Hui H Chang
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Scottsdale, Arizona
| | | | - Paras H Shah
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | - Timothy D Lyon
- Department of Urology, Mayo Clinic, Jacksonville, Florida
| | | | | | - Mark D Tyson
- Department of Urology, Mayo Clinic, Phoenix, Arizona
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Tyson MD, Morris D, Palou J, Rodriguez O, Mir MC, Dickstein RJ, Guerrero-Ramos F, Scarpato KR, Hafron JM, Messing EM, Cutie CJ, Maffeo JC, Raybold B, Chau A, Stromberg KA, Keegan KA. Reply by Authors. J Urol 2023; 209:900. [PMID: 37026638 DOI: 10.1097/ju.0000000000003195.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Affiliation(s)
| | | | - Juan Palou
- Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Oscar Rodriguez
- Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | - John C Maffeo
- Janssen Research & Development, Lexington, Massachusetts
| | | | | | | | - Kirk A Keegan
- Vanderbilt University Medical Center, Nashville, Tennessee
- Janssen Research & Development, Lexington, Massachusetts
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Tyson MD, Morris D, Palou J, Rodriguez O, Mir MC, Dickstein RJ, Guerrero-Ramos F, Scarpato KR, Hafron JM, Messing EM, Cutie CJ, Maffeo JC, Raybold B, Chau A, Stromberg KA, Keegan KA. Safety, Tolerability, and Preliminary Efficacy of TAR-200 in Patients With Muscle-invasive Bladder Cancer Who Refused or Were Unfit for Curative-intent Therapy: A Phase 1 Study. J Urol 2023; 209:890-900. [PMID: 37026631 DOI: 10.1097/ju.0000000000003195] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
PURPOSE Half of patients with muscle-invasive bladder cancer worldwide may not receive curative-intent therapy. Elderly or frail patients are most affected by this unmet need. TAR-200 is a novel, intravesical drug delivery system that provides sustained, local release of gemcitabine into the bladder over a 21-day dosing cycle. The phase 1 TAR-200-103 study evaluated the safety, tolerability, and preliminary efficacy of TAR-200 in patients with muscle-invasive bladder cancer who either refused or were unfit for curative-intent therapy. MATERIALS AND METHODS Eligible patients had cT2-cT3bN0M0 urothelial carcinoma of the bladder. TAR-200 was inserted for 4 consecutive 21-day cycles over 84 days. The primary end points were safety and tolerability at 84 days. Secondary end points included rates of clinical complete response and partial response as determined by cystoscopy, biopsy, and imaging; duration of response; and overall survival. RESULTS Median age of the 35 enrolled patients was 84 years, and most were male (24/35, 68.6%). Treatment-emergent adverse events related to TAR-200 occurred in 15 patients. Two patients experienced treatment-emergent adverse events leading to removal of TAR-200. At 3 months, complete response and partial response rates were 31.4% (11/35) and 8.6% (3/35), respectively, yielding an overall response rate of 40.0% (14/35; 95% CI 23.9-57.9). Median overall survival and duration of response were 27.3 months (95% CI 10.1-not estimable) and 14 months (95% CI 10.6-22.7), respectively. Progression-free rate at 12 months was 70.5%. CONCLUSIONS TAR-200 was generally safe, well tolerated, and had beneficial preliminary efficacy in this elderly and frail cohort with limited treatment options.
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Affiliation(s)
| | | | - Juan Palou
- Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Oscar Rodriguez
- Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | - John C Maffeo
- Janssen Research & Development, Lexington, Massachusetts
| | | | | | | | - Kirk A Keegan
- Vanderbilt University Medical Center, Nashville, Tennessee
- Janssen Research & Development, Lexington, Massachusetts
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Lyon TD, Boorjian SA, Tyson MD. In-home Intravesical Therapy: The Future of Nonmuscle-invasive Bladder Cancer Care Delivery? J Urol 2023; 209:656-658. [PMID: 36637416 DOI: 10.1097/ju.0000000000003176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Timothy D Lyon
- Department of Urology, Mayo Clinic, Jacksonville, Florida
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | - Mark D Tyson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Department of Urology, Mayo Clinic, Phoenix, Arizona
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Moses KA, Sprenkle PC, Bahler C, Box G, Carlsson SV, Catalona WJ, Dahl DM, Dall'Era M, Davis JW, Drake BF, Epstein JI, Etzioni RB, Farrington TA, Garraway IP, Jarrard D, Kauffman E, Kaye D, Kibel AS, LaGrange CA, Maroni P, Ponsky L, Reys B, Salami SS, Sanchez A, Seibert TM, Shaneyfelt TM, Smaldone MC, Sonn G, Tyson MD, Vapiwala N, Wake R, Washington S, Yu A, Yuh B, Berardi RA, Freedman-Cass DA. NCCN Guidelines® Insights: Prostate Cancer Early Detection, Version 1.2023. J Natl Compr Canc Netw 2023; 21:236-246. [PMID: 36898362 DOI: 10.6004/jnccn.2023.0014] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
The NCCN Guidelines for Prostate Cancer Early Detection provide recommendations for individuals with a prostate who opt to participate in an early detection program after receiving the appropriate counseling on the pros and cons. These NCCN Guidelines Insights provide a summary of recent updates to the NCCN Guidelines with regard to the testing protocol, use of multiparametric MRI, and management of negative biopsy results to optimize the detection of clinically significant prostate cancer and minimize the detection of indolent disease.
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Affiliation(s)
| | | | - Clinton Bahler
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center
| | - Geoffrey Box
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | - John W Davis
- The University of Texas MD Anderson Cancer Center
| | - Bettina F Drake
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | | | | | | | | | | | | | | | - Lee Ponsky
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Brian Reys
- UT Southwestern Simmons Comprehensive Cancer Center
| | | | | | | | | | | | | | | | - Neha Vapiwala
- Abramson Cancer Center at the University of Pennsylvania
| | - Robert Wake
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
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Alsyouf M, Ladi-Seyedian SS, Konety B, Pohar K, Holzbeierlein JM, Kates M, Willard B, Taylor JM, Liao JC, Kaimakliotis HZ, Porten SP, Steinberg GD, Tyson MD, Lotan Y, Daneshmand S. Is a restaging TURBT necessary in high-risk NMIBC if the initial TURBT was performed with blue light? Urol Oncol 2023; 41:109.e9-109.e14. [PMID: 36435710 DOI: 10.1016/j.urolonc.2022.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/26/2022] [Accepted: 10/30/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate whether a restaging transurethral resection of bladder tumor (TURBT) is necessary in high-risk nonmuscle invasive bladder cancer (NMIBC) if the initial TURBT was performed using blue light (BL) technology. METHODS AND MATERIALS Using the multi-institutional Cysview registry between 2014 and 2021, all consecutive adult patients with known NMIBC (Ta and T1 disease) who underwent TURBT followed by a restaging TURBT within 8 weeks were reviewed. Patients were stratified according to their initial TURBT, BL vs. white light (WL), and compared to determine rates of residual disease and upstaging. Univariate analysis was performed using Mann-Whitney U and chi-square tests, with P < 0.05 considered significant. RESULTS Overall, 115 patients had TURBT for NMIBC followed by a restaging TURBT within 8 weeks and were included in the analysis. Patients who underwent BL compared to WL for their initial TURBT had higher rates of benign pathology on restaging TURBT, although this was not statistically significant (47% vs. 30%; P = 0.08). Of patients with residual tumors on restaging TURBT, there were no differences in rates of Ta (22% vs. 26.5%; P = 0.62), T1 (22% vs. 26.5%; P = 0.62), or CIS (5.5% vs. 13%; P = 0.49) when the initial TURBT was done using BL compared to WL. Rates of upstaging to muscle invasive disease were also not different when initial TURBT was performed using BL compared to WL (3% vs. 4%; P = 0.78). CONCLUSIONS TURBT using BL does not reduce rates of residual disease or risk of upstaging on restaging TURBT in Ta or T1 disease. Thus, a restaging TURBT is still necessary even if initial TURBT was performed using BL.
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Affiliation(s)
- Muhannad Alsyouf
- Department of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Seyedeh-Sanam Ladi-Seyedian
- Department of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | | | | | | | - Max Kates
- The James Buchanan Brady Urological Institute, Johns Hopkins University, Baltimore, MD
| | | | | | | | | | - Sima P Porten
- Department of Urology, University of California San Francisco, San Francisco, CA
| | | | - Mark D Tyson
- Department of Urology, Mayo Clinic Hospital, Phoenix, AZ
| | - Yair Lotan
- UT Southwestern Medical Center, Dallas, TX
| | - Siamak Daneshmand
- Department of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA.
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Tyson MD, Mi L. Preliminary Surgical Outcomes After Single Incision Robotic Cystectomy (SIRC). Urology 2023; 171:127-132. [PMID: 36402270 DOI: 10.1016/j.urology.2022.08.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To report the preliminary surgical outcomes for single incision robotic cystectomy (SIRC). Robotic cystectomy is associated with low utilization rates of orthotopic neobladders due to challenges related to intracorporeal sowing and configuration. A new technique that shortens the learning curve and reduces the incisional footprint may improve outcomes and lead to greater utilization of neobladders. METHODS Patients undergoing SIRC using the Da Vinci Single Port (SP) robot between March 2021 and March 2022 are included in this retrospective study. We report 30-day perioperative outcomes and test the hypothesis that patients undergoing SIRC have lower analgesic requirements by comparing them to a cohort of patients for whom SIRC was attempted but converted to open during the study period. RESULTS Forty-one patients underwent SIRC, with 17 (41%) patients undergoing conversion to open. Of the SIRC patients, 50% underwent orthotopic neobladder reconstruction, and 13% underwent concomitant nephroureterectomy or urethrectomy. The median operative time was 480 minutes, and the median length of hospitalization was 7 days. Seventeen percent required readmission to the hospital, 17% developed small bowel obstruction or ileus, and 13% required a blood transfusion. With respect to analgesic requirements, there were no differences in the median morphine milligram equivalents between the 2 cohorts (SIRC: 81.4; converted: 77.0; P = .64). CONCLUSION We demonstrate that SIRC is safe and feasible with a high neobladder utilization rate. Wider adoption of this technique may lead to greater utilization of neobladders for patients undergoing robotic cystectomy.
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Affiliation(s)
- Mark D Tyson
- Department of Urology, Mayo Clinic, Phoenix, AZ; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Division of Health Care Delivery Research, Mayo Clinic, Phoenix, AZ.
| | - Lanyu Mi
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Division of Health Care Delivery Research, Mayo Clinic, Phoenix, AZ; Department of Qualitative Health Sciences, Divisions of Clinical Trials and Biostatistics, Mayo Clinic, Scottsdale, AZ
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14
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Affiliation(s)
- Mark D Tyson
- Department of Urology, Mayo Clinic Arizona, Phoenix, AZ; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Division of Health Care Delivery Research, Mayo Clinic, Phoenix, AZ
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Durant AM, Chang YH, Faraj KS, Tyson MD. BCG Administration after Prior Radiation Treatment for Prostate Cancer. Clin Genitourin Cancer 2022; 20:591-597. [PMID: 35798647 DOI: 10.1016/j.clgc.2022.06.011] [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: 12/03/2021] [Revised: 06/08/2022] [Accepted: 06/11/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Prostate radiotherapy is associated with worse oncologic outcomes in patients with bladder cancer. The underlying mechanism is incompletely understood but is thought to be related to an altered microenvironment promoting tumorigenesis. However, there is a gap in the literature regarding how the effect of BCG varies according to prior radiotherapy in patients with non-muscle invasive bladder cancer (NMIBC). In this context, we sought to evaluate oncologic outcomes in NMIBC patients who have previously undergone prostate radiotherapy compared to patients with no prior history of pelvic radiotherapy. METHODS This is a retrospective cohort study that includes all patients who received intravesical for NMIBC at our institution from 2001 to 2019. Patients were stratified into 3 cohorts: prior radiotherapy (RT), radical prostatectomy (RP), and no prostate cancer (No PCa). The outcomes of interest were recurrence at 1-year, progression to muscle-invasive bladder cancer (MIBC), and progression to metastatic disease. Comparisons were also made between cohorts with respect to elapsed time from radiation therapy. Wilcoxon rank-sum test was used for comparing continuous variables, while χ2 and Fischer's exact tests were used to examine categorical variables. RESULTS In 199 total patients who underwent BCG for NMIBC, 23 had a prior history of prostate radiotherapy treatment, while 17 underwent prior radical prostatectomy. Overall, 41.2% of patients had recurrence at 1 year. There was no difference in the number of induction or maintenance BCG administrations received between the cohorts within the first year. There was no significant difference in recurrence at 1 year between the 3 cohorts (P = .56). There was also no difference in progression to MIBC or progression to metastatic disease with P = .50 and 0.89, respectively. CONCLUSION The risk of recurrence after induction BCG treatment for high-grade NMIBC does not vary according to prior radiation treatment for prostate cancer.
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Affiliation(s)
- Adri M Durant
- Department of Urology, Mayo Clinic Arizona, Phoenix, AZ
| | - Yu-Hui Chang
- Department of Quantitative Health Sciences, Mayo Clinic Arizona, Scottsdale, AZ
| | | | - Mark D Tyson
- Department of Urology, Mayo Clinic Arizona, Phoenix, AZ
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Faraj KS, Mi L, Tyson MD. Patient, Physician, Hospital Factors Associated With Readmission After Radical Cystectomy. Urol Pract 2022; 9:589-595. [PMID: 37145810 DOI: 10.1097/upj.0000000000000345] [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] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Patient and clinical factors are the most commonly identified variables associated with hospital readmission after radical cystectomy, but other factors may be important drivers of outcomes, such as hospital and physician characteristics. This study investigates the contribution of patient, physician, and hospital factors in hospital readmission after radical cystectomy. METHODS This was a retrospective review of the Surveillance, Epidemiology, and End Results-Medicare database focusing on bladder cancer patients who underwent radical cystectomy between 2007 and 2016. Medicare claims were identified using International Statistical Classification of Diseases-9/-10 or Healthcare Common Procedure Coding System codes from Medicare Provider Analysis and Review or National Claims History claims, from which the annual hospital/physician volumes were calculated and classified as low, medium, and high. A multivariable analysis was done for 90-day readmission as the outcome using a multilevel model to explore the association between readmission and characteristics of patient, hospital, and physician. Models with random intercepts were constructed to consider the variation from hospital and physician. RESULTS Of 3,530 patients, 1,291 (36.6%) were readmitted within 90 days of the index surgery. On multilevel multivariable analysis, factors significantly associated with readmission included continent urinary diversion (OR 1.55, 95% CI 1.21, 2.00), greater National Cancer Institute comorbidity index (2<4 vs 0-<2, OR 1.35, 95% CI 1.05, 1.75; 4+ vs 0-<2, OR 1.76, 95% CI 1.20, 2.58), American Joint Committee on Cancer stage (P = .04), and hospital region (P = .05). Neither hospital volume, physician volume, teaching hospital status, nor National Cancer Institute center designation was associated with hospital readmission. The main source of variation was determined to be the patient factors (95.89%), followed by the physician (1.43%), and then hospital (2.68%) factors. CONCLUSIONS Patient-specific factors are the most important in impacting the odds of readmission after radical cystectomy, while hospital and physician factors contribute minimally to this outcome.
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Affiliation(s)
| | - Lanyu Mi
- Division of Biostatistics, Mayo Clinic, Scottsdale, Arizona
| | - Mark D Tyson
- Department of Urology, Mayo Clinic, Scottsdale, Arizona
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Faraj KS, Bunn WD, Edmonds VS, Tyson MD. The effect of prior prostate cancer treatment on perioperative and pathological outcomes after cystectomy. Can J Urol 2022; 29:11284-11290. [PMID: 36245197] [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] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
INTRODUCTION A comprehensive analysis on outcomes in the perioperative and pathological setting in patients with a prior diagnosis of prostate cancer has not been performed. The objective of this study is to describe the effect of prior prostate cancer treatment on perioperative and pathological outcomes after cystectomy. MATERIALS AND METHODS This was a retrospective review of all male patients who underwent cystectomy at our institution from 01/01/2007-01/01/2020. Patients who were previously diagnosed and treated for prostate cancer were identified and outcomes were assessed. RESULTS In 525 male patients, 132 (25.1%) had a diagnosis of prostate cancer prior to cystectomy. In the patients with a history of prostate cancer, 59 (46.2%) patients underwent prior radical prostatectomy (RP), 52 (39.4%) underwent some form of radiation therapy and the remaining 21 were managed with other modalities, including 11.4% who were on active surveillance. When comparing perioperative outcomes, there were no significant differences in outcomes. Pathological outcomes revealed that pT4 disease was more common in the RT cohort (19.2%, p = 0.05). In patients with no history of prostate cancer, 151 (40.2%) were found to have incidental prostate cancer at the time of cystectomy. Most (67.5%) patients with incidental prostate cancer had Gleason < 7 disease and only 1.3% developed metastatic prostate cancer on follow up, compared to over 10% of the patients previously treated for prostate cancer (p < 0.05). CONCLUSIONS Patients who underwent prostate cancer treatment prior to cystectomy may be at increased risk for worse perioperative and pathologic outcomes after cystectomy.
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Affiliation(s)
- Kassem S Faraj
- Department of Urology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Weslyn D Bunn
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, USA
| | | | - Mark D Tyson
- Department of Urology, Mayo Clinic Hospital, Phoenix, Arizona, USA
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Faraj KS, Durant A, Mauler D, Choudry M, Singh R, Chang YH, Tyson MD. Extended Anticoagulation after Radical Cystectomy Using Direct Acting Oral Anticoagulants: A Single-Institutional Experience. Urol Pract 2022; 9:451-458. [PMID: 37145730 DOI: 10.1097/upj.0000000000000330] [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: 03/08/2022] [Accepted: 05/22/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Extended prophylactic anticoagulation therapy with enoxaparin 40 mg daily is effective in reducing the incidence of venous thromboembolism (VTE) after radical cystectomy. In an effort to improve compliance, we modified our extended anticoagulation options to direct oral anticoagulants (DOAs; eg apixaban 2.5 mg twice daily or rivaroxaban 10 mg daily). This study assesses our experience with extended VTE prophylaxis using DOAs. METHODS This is a retrospective review that included all patients who underwent radical cystectomy at our institution between January 2007 and June 2021. Multivariable logistic regression models were constructed to test the hypothesis that use of extended DOAs is similar to enoxaparin in terms of VTE events and risk of gastrointestinal bleeding. RESULTS In 657 patients, the median age was 71 years. Of the 101 patients who received extended VTE prophylaxis, 46 (45.5%) patients received rivaroxaban/apixaban. At 90 days of followup, 40 patients (7.2%) who did not receive extended prophylaxis on discharge developed a VTE compared to 2 patients (3.6%) in the enoxaparin group and 0 patients in the DOA group (p=0.11). Seven patients (1.3%) who did not receive extended anticoagulation developed gastrointestinal bleeding compared to 0 patients in the enoxaparin group and 1 (2.2%) in the DOA group (p=0.60). On multivariable analysis, both enoxaparin and DOAs were associated with similar reductions in the risk of developing VTE compared to controls (enoxaparin: OR 0.33, p=0.09 and DOAs: OR 0.19, p=0.15). CONCLUSIONS These preliminary data suggest that oral apixaban and rivaroxaban are acceptable alternatives to enoxaparin with similar safety and efficacy profiles.
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Affiliation(s)
| | - Adri Durant
- Department of Urology, Mayo Clinic, Scottsdale, Arizona
| | | | | | - Rohan Singh
- Department of Urology, Mayo Clinic, Scottsdale, Arizona
| | | | - Mark D Tyson
- Department of Urology, Mayo Clinic, Scottsdale, Arizona
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Faraj KS, Bunn W, Durant AM, Mauler D, Chang YHH, Tyson MD. A comparison of naloxegol versus alvimopan at the time of cystectomy and urinary diversion. Can J Urol 2022; 29:11209-11215. [PMID: 35969724] [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] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION The use of alvimopan at the time of cystectomy has been associated with improved perioperative outcomes. Naloxegol is a less costly alternative that has been used in some centers. This study aims to compare the perioperative outcomes of patients undergoing cystectomy with urinary diversion who receive the mu-opioid antagonist alvimopan versus naloxegol. MATERIALS AND METHODS This was a retrospective review that included all patients who underwent cystectomy with urinary diversion at our institution between 2007-2020. Comparisons were made between patients who received perioperative alvimopan, naloxegol and no mu-opioid antagonist (controls). RESULTS In 715 patients who underwent cystectomy, 335 received a perioperative mu-opioid antagonist, of whom 57 received naloxegol. Control patients, compared to naloxegol and alvimopan patients, experienced a significantly (p < 0.05) delayed return of bowel function (4.3 vs. 2.5 vs. 3.0 days) and longer hospital length of stay (7.9 vs. 7.5 vs. 6.5 days), respectively. The incidence of nasogastric tube use (14.2% vs. 12.5% vs. 6.5%) and postoperative ileus (21.6% vs. 21.1% vs. 13.3%) was also most common in the control group compared to the naloxegol and alvimopan cohorts, respectively. A multivariable analysis revealed that when comparing naloxegol and alvimopan, there was no difference in return of bowel function (OR 0.88, p = 0.17), incidence of postoperative ileus (OR 1.60, p = 0.44), or hospital readmission (OR 1.22, p = 0.63). CONCLUSIONS Naloxegol expedites the return of bowel function to the same degree as alvimopan in cystectomy patients. Given the lower cost of naloxegol, this agent may be a preferable alternative to alvimopan.
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Affiliation(s)
- Kassem S Faraj
- Department of Urology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Weslyn Bunn
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, USA
| | - Adri M Durant
- Department of Urology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - David Mauler
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, USA
| | - Yu-Hui H Chang
- Department of Biostatistics, Mayo Clinic, Scottsdale, Arizona, USA
| | - Mark D Tyson
- Department of Urology, Mayo Clinic Hospital, Phoenix, Arizona, USA
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Olson KM, Faraj KS, Singh P, Tyson MD. Treatment of Upper Tract Urothelial Carcinoma. Urol Oncol 2022. [DOI: 10.1007/978-3-030-89891-5_20] [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: 10/19/2022]
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Ahmadi H, Ladi-Seyedian SS, Konety B, Pohar K, Holzbeierlein JM, Kates M, Willard B, Taylor JM, Liao JC, Kaimakliotis HZ, Porten SP, Steinberg GD, Tyson MD, Lotan Y, Daneshmand S. Role of blue-light cystoscopy in detecting invasive bladder tumours: data from a multi-institutional registry. BJU Int 2021; 130:62-67. [PMID: 34637596 DOI: 10.1111/bju.15614] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/16/2021] [Accepted: 09/27/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate the role of blue-light cystoscopy (BLC) in detecting invasive tumours that were not visible on white-light cystoscopy (WLC). PATIENTS AND METHODS Using the multi-institutional Cysview registry database, patients who had at least one white-light negative (WL-)/blue-light positive (BL+) lesion with invasive pathology (≥T1) as highest stage tumour were identified. All WL-/BL+ lesions and all invasive tumours in the database were used as denominators. Relevant baseline and outcome data were collected. RESULTS Of the 3514 lesions (1257 unique patients), 818 (23.2%) lesions were WL-/BL+, of those, 55 (7%) lesions were invasive (48 T1, seven T2; 47 unique patients) including 28/55 (51%) de novo invasive lesions (26 unique patients). In all, 21/47 (45%) patients had WL-/BL+ concommitant carcinoma in situ and/or another T1 lesions. Of 22 patients with a WL-/BL+ lesion who underwent radical cystectomy (RC), high-risk pathological features leading to RC was only visible on BLC in 18 (82%) patients. At time of RC, 11/22 (50%) patients had pathological upstaging including four (18%) with node-positive disease. CONCLUSIONS A considerable proportion of invasive lesions are only detectable by BLC and the rate of pathological upstaging is significant. Our present findings suggest an additional benefit of BLC in the detection of invasive bladder tumours that has implications for treatment approach.
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Affiliation(s)
- Hamed Ahmadi
- Department of Urology, USC Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Seyedeh Sanam Ladi-Seyedian
- Department of Urology, USC Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | | | | | | | - Max Kates
- The James Buchanan Brady Urological Institute, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | | | - Sima P Porten
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | | | - Mark D Tyson
- Department of Urology, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Yair Lotan
- UT Southwestern Medical Center, Dallas, TX, USA
| | - Siamak Daneshmand
- Department of Urology, USC Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
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Faraj KS, Judge N, Chang YHH, Blodgett G, Stanton ML, Tyson MD. Variation in Lymph Node Yield After Radical Cystectomy. Am J Clin Pathol 2021; 156:391-398. [PMID: 33608695 DOI: 10.1093/ajcp/aqaa247] [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] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To test the hypothesis that lymph node yield will vary by pathology assistant (PA) in patients undergoing radical cystectomy (RC) with pelvic lymph node dissection (PLND). METHODS This is a single-institution retrospective review that included patients who underwent an RC with PLND for bladder cancer from January 1, 2007, to January 1, 2018. Predicted mean lymph node counts were generated using multivariable regression analysis. RESULTS In a total of 430 patients who underwent RC with PLND, the median lymph node count (interquartile range) was 15.0 (11.0-21.0). The frequency of the limits of lymphadenectomy was as follows: external iliac, internal iliac, and obturator (true pelvis) (33.3%); true pelvis plus common iliac to the level of the aortic bifurcation (47.9%); and inferior mesenteric artery (18.8%). On descriptive analysis, there were differences in lymph node yield when evaluating the following variables: level of dissection, clinical stage, neoadjuvant chemotherapy, surgical approach, surgeon, pathologist, and PA (P < .05). On multivariable analysis, adjusted lymph node counts varied between surgeons, pathologists, clinical stage, and level of dissection but not by PA (P = .18). CONCLUSIONS Lymph node yield after RC varies on several known levels, including surgeon, extent of lymphadenectomy, clinical stage, and pathologist. This study found no significant variation in lymph node yield according to PA.
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Affiliation(s)
| | | | | | - Gail Blodgett
- Patient Collaboration, Mayo Clinic, Scottsdale, AZ, USA
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Findlay BL, Britton CJ, Glasgow AE, Gettman MT, Tyson MD, Pak RW, Viers BR, Habermann EB, Ziegelmann MJ. Long-term Success With Diminished Opioid Prescribing After Implementation of Standardized Postoperative Opioid Prescribing Guidelines: An Interrupted Time Series Analysis. Mayo Clin Proc 2021; 96:1135-1146. [PMID: 33958051 DOI: 10.1016/j.mayocp.2020.10.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 10/21/2020] [Accepted: 10/29/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess longitudinal prescribing patterns for patients undergoing urologic surgery in the nearly 2-year time frame before and after implementation of an evidence-based opioid prescribing guideline to accurately characterize the impact on postoperative departmental practices. PATIENTS AND METHODS Historical prescribing data for adults who underwent 21 urologic procedures at 3 academic institutions were used to derive a 4-tiered guideline for postoperative opioid prescribing. The guideline was implemented on January 16, 2018, and prescribing patterns including quantity of opioids prescribed (in oral morphine equivalents [OMEs]) and refill rates were compared for opioid-naïve patients undergoing urologic surgery before (January 1, 2016, through January 15, 2018; N=10,649) and after (January 16, 2018, through September 30, 2019; N=9422) guideline implementation. Univariate analysis was performed using Wilcoxon rank sum and χ2 tests. Cochran-Armitage trend tests and interrupted time series analysis were used to test for significance in the change in OMEs prescribed before vs after guideline implementation. RESULTS The median quantity of opioids decreased from 150 OMEs (interquartile range, 0-225) before guideline implementation to 0 OMEs (interquartile range, 0-90) after guideline implementation (P<.001). Median OMEs decreased significantly in each tier and each of 21 individual procedures. Overall guideline adherence was 90.7% (n=8547). Despite this decrease in OMEs prescribed, post-guideline implementation patients obtained fewer refills than the pre-guideline implementation group (614 [6.5%] vs 999 [9.4%]; P<.001). CONCLUSION In a multi-institutional follow-up prospective study of adult urologic surgery-specific evidence-based guidelines for postoperative prescribing, we demonstrate sustained reduction in OMEs prescribed secondary to guideline implementation and adherence by our providers.
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Affiliation(s)
| | | | - Amy E Glasgow
- The Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN
| | | | - Mark D Tyson
- Department of Urology, Mayo Clinic, Scottsdale, AZ
| | - Raymond W Pak
- Department of Urology, Mayo Clinic, Jacksonville, FL
| | - Boyd R Viers
- Department of Urology, Mayo Clinic, Rochester, MN
| | - Elizabeth B Habermann
- The Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN
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Faraj KS, Edmonds VS, Snider SL, Bunn WD, Tyson MD. Timing of perioperative transversus abdominis plane block at the time of radical cystectomy does not affect perioperative outcomes. Int Urol Nephrol 2021; 53:2019-2025. [PMID: 33905042 DOI: 10.1007/s11255-021-02872-0] [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: 03/11/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The transversus abdominis plane (TAP) block has been effective in providing adequate pain control, limiting opioid use, and improving perioperative outcomes in patients undergoing major abdominal surgeries. Little is known regarding the efficacy of preoperative (pre-incisional) versus postoperative TAP block in patients who undergo cystectomy. METHODS This is a retrospective study that reviewed all patients who underwent cystectomy between January 2011 and January 2020 at a single institution. Patients were stratified into three cohorts: preoperative TAP block, postoperative TAP block, no TAP block. A multivariable linear regression model was constructed that assessed factors associated with total morphine milligram equivalents (MME) per hospital stay. RESULTS In 463 patients, baseline characteristics were similar. There were 66(14.3%) patients who received a perioperative TAP block, 16 (24.2%) of whom received a preoperative TAP block. There were no significant differences in baseline factors. A TAP block was associated with lower MME used per day (41.8 mg vs 53.1 mg, p = 0.009) and per hospital stay (232 mg vs 320.5 mg, p = 0.001). The median MME per hospital stay and per day was lowest in the preoperative TAP cohort (194.0 mg, p = 0.011 and 38.0 mg, p = 0.042, respectively). On multivariable analysis of a subset of patients who received a TAP block, there was no significant difference in MME use in patients who received a preoperative vs postoperative TAP block (- 84.8, p = 0.339). CONCLUSION The use of TAP blocks was associated with lower MME use in the entire population; however, there was no difference in MME use when comparing preoperative and postoperative TAP blocks.
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Affiliation(s)
- Kassem S Faraj
- Department of Urology, Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA.
| | | | - Sam L Snider
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Weslyn D Bunn
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Mark D Tyson
- Department of Urology, Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
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Faraj KS, Rose KM, Navaratnam AK, Abdul-Muhsin HM, Eversman S, Singh V, Tyson MD. Effect of intracorporeal urinary diversion on the incidence of benign ureteroenteric stricture after cystectomy. Int J Urol 2021; 28:593-597. [PMID: 33594730 DOI: 10.1111/iju.14521] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 01/12/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To compare ureteroenteric stricture rates after radical cystectomy in patients who undergo an intracorporeal urinary diversion versus other surgical approaches. METHODS We retrospectively reviewed health records of all patients who underwent cystectomy with urinary diversion at Mayo Clinic Hospital (Phoenix, AZ, USA) from 1 January 2007 through 1 January 2018. Ureteroenteric stricture was identified by surveillance imaging. Patients were stratified by surgical approach: open radical cystectomy, robot-assisted radical cystectomy with extracorporeal urinary diversion and robot-assisted radical cystectomy-intracorporeal urinary diversion. A Cox proportional hazards model was fitted that included independent predictors of stricture development. RESULTS Of the 573 cystectomies assessed, 236 (41.2%) were carried out robotically. In the robot-assisted radical cystectomy cohort, 39 patients (16.5%) underwent intracorporeal urinary diversion. The median follow-up period was 55, 70 and 71 months for the open radical cystectomy, robot-assisted radical cystectomy-extracorporeal urinary diversion and robot-assisted radical cystectomy-intracorporeal urinary diversion groups, respectively. Subgroup stricture rates were as follows: open radical cystectomy, 8.0%; robot-assisted radical cystectomy-extracorporeal urinary diversion, 9.6%; and robot-assisted radical cystectomy-intracorporeal urinary diversion, 2.6% (P = 0.33). The median time to stricture was 5 months (interquartile range 3.3-11.5 months). In the bivariable analysis, factors that were associated with the development of ureteroenteric stricture were postoperative urinary leak (hazard ratio 3.177, 95% confidence interval 1.129-8.935; P = 0.03) and body mass index (hazard ratio 1.078, 95% confidence interval 1.027-1.132; P = 0.002). On multivariable logistic regression analysis, intracorporeal urinary diversion approach was not associated with the development of ureteroenteric stricture (hazard ratio 0.272, 95% confidence interval 0.036-2.066; P = 0.21). CONCLUSIONS Ureteroenteric stricture is a complication that typically occurs within the first postoperative year. Although our results did not support major differences in outcomes between intracorporeal urinary diversion and extracorporeal urinary diversion, the small sample size did not exclude the possibility of a type 2 statistical error.
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Affiliation(s)
- Kassem S Faraj
- Department of Urology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Kyle M Rose
- Department of Urology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | | | | | - Sarah Eversman
- Department of Urology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Vijay Singh
- Department of Urology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Mark D Tyson
- Department of Urology, Mayo Clinic Hospital, Phoenix, Arizona, USA
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Nevo A, Stern KL, Moore JP, Humphreys MR, Tyson MD, Keddis MT. The impact of phone counseling on urinary stone prevention. World J Urol 2020; 39:1625-1629. [PMID: 32588206 DOI: 10.1007/s00345-020-03320-x] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/16/2020] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE We compared the effect of standard office-based consultation (OC) and phone correspondences (PC) on dietary 24-h urinary parameters. METHODS The medical record of all patients treated between January and April 2019 was reviewed. Only patients who had at least two consecutive 24-h urine collections were included. Linear and logistic regressions were used to investigate the difference between the changes in urinary parameters after OC and PC. RESULTS Forty-three patients underwent 135 OC and 34 PC. Twenty-one received OC and PC, and 22 had only OC. Gender, age, the distance to stone clinic, the number of previous stone episodes, and baseline urinary parameters were similar between the groups. Patients who had both OC and PC had a longer follow-up time (51.7 vs 18.5 months, p < 0.0001) as well as more consults (Median 5.4 vs 2.5, p < 0.0001). Six (27%) patients who had only OC, and eight (38%) patients who had both OC and PC, experienced stone recurrence during the study period (p = 0.52). Following PC, there was a greater improvement in urine volume in comparison to OC (0.27 l/day vs -0.06 l/day, p = 0.034), but there was no difference in the absolute values after the consults between the groups. CONCLUSION In established stone-clinic patients, PC was associated with a better adherence with follow-up. The 24-h urine results were similar between PC and OC. PC may be an effective alternative for urinary stone management.
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Affiliation(s)
- Amihay Nevo
- Department of Urology, Mayo Clinic, Arizona, USA.
| | | | | | | | - Mark D Tyson
- Department of Urology, Mayo Clinic, Arizona, USA
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Faraj KS, Mi L, Eversman S, Singh R, DeLucia NM, Blodgett G, Swanson SK, Andrews PE, Ferrigni RG, Humphreys MR, Castle EP, Tyson MD. The effect of urinary diversion on long-term kidney function after cystectomy. Urol Oncol 2020; 38:796.e15-796.e21. [PMID: 32482512 DOI: 10.1016/j.urolonc.2020.05.003] [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: 01/03/2020] [Revised: 03/26/2020] [Accepted: 05/04/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Cystectomy with urinary diversion is associated with decreased long-term kidney function due to several factors. One factor that has been debated is the type of urinary diversion used: ileal conduit (IC) vs. neobladder (NB). We tested the hypothesis that long-term kidney function will not vary by type of urinary diversion. METHODS AND MATERIALS We retrospectively identified all patients who underwent cystectomy with urinary diversion at our institution from January 1, 2007, to January 1, 2018. Data were collected on patient demographics, comorbid conditions, perioperative radiotherapy, and complications. Creatinine values were measured at several time points up to 120 months after surgery. Glomerular filtration rate (GFR) (ml/min per 1.73 m2) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. A linear mixed model with inverse probability of treatment weighting (IPTW) was used to compare GFR between the IC and NB cohorts over time. Multiple sensitivity analyses were performed based on 2 different calculations of GFR (Chronic Kidney Disease Epidemiology Collaboration equation vs. Modification of Diet in Renal Disease), with and without excluding patients with preoperative GFR less than 40 ml/min per 1.73 m2. RESULTS Among 563 patients who underwent cystectomy with urinary diversion, a NB was used for 72 (12.8%) individuals. Patients who had a NB were significantly younger, had a lower American Society of Anesthesiologists score, greater baseline GFR, better Eastern Cooperative Oncology Group performance status, lower median Charlson comorbidity index, and were less likely to have received preoperative abdominal radiation (all P < 0.05). Both NB and IC patients had decreased kidney function over time, with mean GFR losses at 5 years of 17% and 14% of baseline values, respectively. The IPTW-adjusted linear mixed model revealed that IC patients had slightly more deterioration in kidney function over time, but this was not statistically significant (estimate, 0.12; P = 0.06). The sensitivity analyses yielded a similar trend, in that GFR decrease appeared to be greater in the IC cohort. This trend was statistically significant when using Modification of Diet in Renal Disease (P = 0.04). CONCLUSIONS Among highly selected patients with an NB, deterioration of kidney function may potentially be lower over time than among IC patients. However, the statistical significance varied between analyses and we cautiously attribute these observed differences to patient selection.
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Affiliation(s)
- Kassem S Faraj
- Department of Urology (Drs Faraj, Swanson, Andrews, Ferrigni, Humphreys, Castle, and Tyson), Mayo Clinic Hospital, Phoenix, Arizona
| | - Lanyu Mi
- Biostatistics (Ms Mi), Mayo Clinic, Scottsdale, Arizona
| | - Sarah Eversman
- Ms Eversman is a student, Creighton University, Omaha, Nebraska
| | - Rohan Singh
- Mr Singh is a student, Arizona State University, Tempe, Arizona
| | - Noel M DeLucia
- Division of Research Administrative Services (Ms DeLucia), Mayo Clinic Hospital, Phoenix, Arizona
| | - Gail Blodgett
- Patient Collaborator (Ms Blodgett), Mayo Clinic Hospital, Phoenix, Arizona
| | - Scott K Swanson
- Department of Urology (Drs Faraj, Swanson, Andrews, Ferrigni, Humphreys, Castle, and Tyson), Mayo Clinic Hospital, Phoenix, Arizona
| | - Paul E Andrews
- Department of Urology (Drs Faraj, Swanson, Andrews, Ferrigni, Humphreys, Castle, and Tyson), Mayo Clinic Hospital, Phoenix, Arizona
| | - Robert G Ferrigni
- Department of Urology (Drs Faraj, Swanson, Andrews, Ferrigni, Humphreys, Castle, and Tyson), Mayo Clinic Hospital, Phoenix, Arizona
| | - Mitchell R Humphreys
- Department of Urology (Drs Faraj, Swanson, Andrews, Ferrigni, Humphreys, Castle, and Tyson), Mayo Clinic Hospital, Phoenix, Arizona
| | - Erik P Castle
- Department of Urology (Drs Faraj, Swanson, Andrews, Ferrigni, Humphreys, Castle, and Tyson), Mayo Clinic Hospital, Phoenix, Arizona
| | - Mark D Tyson
- Department of Urology (Drs Faraj, Swanson, Andrews, Ferrigni, Humphreys, Castle, and Tyson), Mayo Clinic Hospital, Phoenix, Arizona.
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Faraj KS, Judge NZ, Rose KM, Eversman S, Richards J, Blodgett G, Singh V, DeLucia NM, Humphreys MR, Castle EP, Tyson MD. How the Beneficial Effects of Alvimopan Differ With Surgical Approach for Radical Cystectomy. Urology 2020; 140:107-114. [DOI: 10.1016/j.urology.2019.12.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/12/2019] [Accepted: 12/19/2019] [Indexed: 12/30/2022]
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Faraj KS, Tyson MD. AUTHOR REPLY. Urology 2020; 140:114. [DOI: 10.1016/j.urology.2019.12.060] [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: 11/04/2019] [Accepted: 12/19/2019] [Indexed: 10/24/2022]
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Kamat AM, Lerner SP, O'Donnell M, Georgieva MV, Yang M, Inman BA, Kassouf W, Boorjian SA, Tyson MD, Kulkarni GS, Chang SS, Konety BR, Svatek RS, Balar A, Witjes JA. Evidence-based Assessment of Current and Emerging Bladder-sparing Therapies for Non-muscle-invasive Bladder Cancer After Bacillus Calmette-Guerin Therapy: A Systematic Review and Meta-analysis. Eur Urol Oncol 2020; 3:318-340. [PMID: 32201133 DOI: 10.1016/j.euo.2020.02.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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: 11/16/2019] [Revised: 01/15/2020] [Accepted: 02/25/2020] [Indexed: 10/24/2022]
Abstract
CONTEXT Currently, there is no standard of care for patients with non-muscle-invasive bladder cancer (NMIBC) who recur despite bacillus Calmette-Guerin (BCG) therapy. Although radical cystectomy is recommended, many patients decline to undergo or are ineligible to receive it. Multiple agents are being investigated for use in this patient population. OBJECTIVE To systematically synthesize and describe the efficacy and safety of current and emerging treatments for NMIBC patients after treatment with BCG. EVIDENCE ACQUISITION A systematic literature search of MEDLINE, Embase, and the Cochrane Controlled Register of Trials (period limited to January 2007-June 2019) was performed. Abstracts and presentations from major conference proceedings were also reviewed. Randomized controlled trials were assessed using the Cochrane risk of bias tool. Data for single-arm trials were pooled using a random-effect meta-analysis with the proportions approach. Trials were grouped based on the minimum number of prior BCG courses required before enrollment and further stratified based on the proportion of patients with carcinoma in situ (CIS). EVIDENCE SYNTHESIS Thirty publications were identified with data from 23 trials for meta-analysis, of which 17 were single arm. Efficacy and safety outcomes varied widely across studies. Heterogeneity across trials was reduced in subgroup analyses. The pooled 12-mo response rates were 24% (95% confidence interval [CI]: 16-32%) for trials with two or more prior BCG courses and 36% (95% CI: 25-47%) for those with one or more prior BCG courses. In a subgroup analysis, inclusion of ≥50% of patients with CIS was associated with a lower response. CONCLUSIONS The variability in efficacy and safety outcomes highlights the need for consistent endpoint reporting and patient population definitions. With promising emerging treatments currently in development, efficacious and safe therapeutic options are urgently needed for this difficult-to-treat patient population. PATIENT SUMMARY We examined the efficacy and safety outcomes of treatments for non-muscle-invasive bladder cancer after bacillus Calmette-Guerin therapy. Outcomes varied across studies and patient populations, but emerging treatments currently in development show promising efficacy.
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Affiliation(s)
- Ashish M Kamat
- University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - J Alfred Witjes
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Rose KM, Navaratnam AK, Faraj KS, Abdul-Muhsin HM, Syal A, Elias L, Moss AA, Eversman WG, Stone WM, Money SR, Davila VJ, Tyson MD, Castle EP. Comparison of Open and Robot Assisted Radical Nephrectomy With Level I and II Inferior Vena Cava Tumor Thrombus: The Mayo Clinic Experience. Urology 2020; 136:152-157. [DOI: 10.1016/j.urology.2019.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/24/2019] [Accepted: 11/02/2019] [Indexed: 10/25/2022]
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Faraj KS, Abdul-Muhsin HM, Navaratnam AK, Rose KM, Stagg J, Ho TH, Bryce AH, Cheney SM, Tyson MD, Castle EP. Role of robot-assisted retroperitoneal lymph node dissection in malignant mesothelioma of the tunica vaginalis: case series and review of the literature. Can J Urol 2019; 26:9752-9757. [PMID: 31180304] [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: 06/09/2023]
Abstract
INTRODUCTION The management of malignant mesothelioma of the tunica vaginalis (MMTVT) is not clearly defined. Retroperitoneal lymph node dissection has been reported as a potential management option. Herein we present our experience with robot-assisted retroperitoneal lymph node dissection (RARPLND) in our series of patients with MMTVT. MATERIALS AND METHODS The Mayo Clinic cancer registry was queried from 1972-present for all patients who had a diagnosis of MMTVT. Six patients were identified, five of whom were treated with RPLND, where four underwent RARPLND. RESULTS In five patients who underwent RPLND, the median age was 50 years (IQR 34-51). Four patients originally presented with right sided symptomatic hydroceles, while one presented with right sided chronic epididymitis. Orchiectomy (one simple, two inguinal radical) was performed in three patients prior to presentation. Preoperative cross-sectional imaging, including PET-CT scan in three patients, was negative for lymphadenopathy or metastasis. RARPLND was performed in 4/5 (80%) cases and concomitant hemiscrotectomy in 4/5 (80%) cases. Full bilateral template was performed in three patients and right modified template was performed in the remaining two. Median lymph node yield was 29 (IQR 22-32) and median blood loss was 275 cc (IQR 200-300). Positive retroperitoneal lymph nodes were found in 3/5 (60%) cases. All patients who underwent RARPLND were discharged home on postoperative day one. Mean follow up was 27 months (range 3-47). No patients recurred. CONCLUSIONS Regardless of the approach, RPLND may provide a diagnostic benefit in patients who present with MMTVT, with the robotic approach affording a potentially expedited recovery.
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Affiliation(s)
- Kassem S Faraj
- Department of Urology, Mayo Clinic Hospital, Phoenix, Arizona, USA
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Faraj K, Rose K, Abdul-Muhsin H, Navaratnam A, Patton M, Cheney S, Tyson MD, Castle EP. Robot-assisted radical cystectomy (RARC) versus open radical cystectomy (ORC): Oncological outcomes in 469 patients with a mean follow-up of five years. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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
492 Background: There is scant information about intermediate and long-term comparative outcomes between RARC and ORC, with the exception of a recent, small randomized-trial. We present our experience with RARC and ORC in managing bladder cancer patients who require cystectomy. Methods: A query of all patients who underwent radical cystectomy for a primary bladder tumor between 01/2007 and 6/2017 at our institution yield 469 patients. Data was collected on patient demographics, pre-operative information, operative details, pathology, and follow-up. Most RARCs were performed by a high-volume robotic surgeon who preferentially used the robotic approach at the start of all cases. Statistical analyses were generated using SPSS 22.0. Any open conversions were analyzed in the RARC cohort. Results: In 469 total patients, 197 (42.0%) and 272 (58.0%) underwent RARC and ORC, respectively. There were 163 (82.7%) and 224 (82.4%) males in each group and the mean ages (SD) were 71.5 (8.6) and 70.2 (10.5) years. Mean follow-up (SD) was 75 (37.7) and 61 (35.7) months, respectively. There were 130 (66.0%) and 172 (63.2%) patients who presented with T2 or greater disease (p=0.605). Soft-tissue margin rates were 4.1% for RARC and 6.7% for ORC patients (p=0.232). Neoadjuvant chemotherapy was used in 56.9% of RARC and 45.9% of ORC patients with ≥ cT2 disease (p=0.058). The 5-year overall survival was 60.0% vs 57.0% and the 10-year overall survival was 40.3% vs 44.8% for RARC vs. ORC patients, respectively (p=0.283). The 5-year recurrence-free survival was survival (RFS) was 71.7% vs 65.7% and the 10-year RFS was 70.5% vs 62.3% for the RARC vs. open groups, respectively (p=0.078). Aggressive histological variants, which were associated with greater likelihood for recurrence, were more common in the ORC group (13.7 vs. 22.4% p=0.013). Atypical recurrences (i.e. peritoneal, extrapelvic nodes) occurred in 6 (3.0%) and 14 (5.1%) RARC and ORC patients, respectively (p=0.266). Conclusions: In experienced hands, intermediate and long-term outcomes of RARC appear equivalent to ORC with regards to recurrence free survival, overall survival, and risk of atypical recurrences.
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Faraj K, Abdul-Muhsin H, Navaratnam A, Rose K, Ho TH, Bryce AH, Singh P, Cheney S, Tyson MD, Castle EP. Role of robot assisted retroperitoneal lymph node dissection in metastatic malignant mesothelioma of the tunica vaginalis: Case series. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.536] [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
536 Background: The management of malignant mesothelioma of the tunica vaginalis of the testes (MMTVT) is not clearly defined, though retroperitoneal lymph node dissection has been reported as a diagnostic and potentially therapeutic option. Herein we present our experience with robot assisted retroperitoneal lymph node dissection (RARPLND) in a series of patients with MMTVT. Methods: The Mayo Clinic cancer registry was queried from 1972-present for all patients who had a diagnosis of MMTVT. Six patients were identified, five of whom were treated with RPLND, where four underwent RARPLND. Data was collected on pertinent demographic, preoperative, perioperative, postoperative outcomes and follow-up oncological data. Results: In five patients who underwent RPLND, the median age was 50 years (IQR 34-51), median BMI was 26.9 (IQR 26.4-30.6). Four patients originally presented with right sided symptomatic hydroceles, while one presented with right sided chronic epididymitis. Orchiectomy (one simple, two inguinal radical) was performed in three patients and hydrocelectomy in the other two patients prior to presentation. Preoperative cross-sectional imaging, including PET-CT scan in three patients, was negative for lymphadenopathy or metastasis. RARPLND was performed in 4/5 (80%) cases and concomitant hemiscrotectomy in 4/5 (80%) cases. Full bilateral template was performed in three patients and right modified template was performed in the remaining two. Median lymph node yield was 29 (IQR 22-32) and median blood loss was 275 cc (IQR 200-300). Positive retroperitoneal lymph nodes were found in 3/5 (60%) cases. Final margins of hemiscrotectomy were negative in all four cases. All patients who underwent RARPLND were discharged home on postoperative day one. One patient received four cycles of adjuvant Cisplatin and Pemetrexed. Mean follow-up was 27 months (range 2-47). No patients recurred. Conclusions: MMTVT is a very rare malignancy with high potential for retroperitoneal lymph node dissemination. Regardless of the approach, RPLND may provide both a diagnostic and therapeutic benefit, with the robotic approach affording a potentially expedited recovery.
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Packiam VT, Tsivian M, Tyson MD, Lohse CM, Cheville JC, Boorjian SA, Leibovich BC, Thompson RH. The association of anxiety and depression with mortality risk among patients with clear cell renal cell carcinoma undergoing nephrectomy. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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
617 Background: Anxiety and depression are psychosocial factors which have been demonstrated to have mixed interactions with mortality across various malignancies. While these variables have been associated with poor overall survival for patients with metastatic RCC, the influence on outcomes for localized RCC has been poorly studied. We evaluated the association of anxiety or depression with survival in patients with surgically treated localized clear cell RCC (ccRCC). Methods: We performed retrospective review of our institutional nephrectomy registry to identify 1,990 patients who underwent radical or partial nephrectomy for unilateral, sporadic, non-metastatic ccRCC between 1995- 2011. Baseline anxiety and depression were identified using ICD-9 codes. Associations of anxiety or depression with outcomes of interest were evaluated using Cox proportional hazards models. Two propensity score (PS) techniques were used: adjusting for PS quintile and re-weighting by stabilized inverse probability weights. Results: A total of 197 (10%) patients had diagnoses of anxiety or depression (57 had anxiety alone, 107 had depression alone, and 33 had both anxiety and depression). Median follow-up among survivors was 10.0 (IQR 7.3-13.6) years, during which time 864 died, including 363 from RCC. Patients with anxiety or depression were younger (mean age 59 vs 62 years, p < 0.001) and had more recent operations (75% vs 47% in 2005-2011, p < 0.001) compared to those with neither diagnosis. After PS adjustment, all clinical and pathologic features were well balanced between groups. After PS adjustment, there were no significant differences in time to local ipsilateral recurrence, distant metastases, and death from RCC between groups. We did note a trend to poorer overall survival in patients with anxiety or depression (HR 1.29, 95%CI = 0.98-1.69, p = 0.065). Conclusions: Our results suggest that neither anxiety nor depression is significantly associated with oncologic outcomes among patients with localized surgically treated ccRCC. The trend toward worse overall survival among patients with anxiety or depression warrants further investigation.
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Faraj K, Chang YHH, Neville MR, Blodgett G, Etzioni DA, Habermann EB, Andrews PE, Castle EP, Humphreys MR, Tyson MD. Robotic vs. open cystectomy: How length-of-stay differences relate conditionally to age. Urol Oncol 2019; 37:354.e1-354.e8. [PMID: 30770298 DOI: 10.1016/j.urolonc.2019.01.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 10/15/2018] [Revised: 12/20/2018] [Accepted: 01/28/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The length-of-stay (LOS) benefit of minimally invasive cystectomy varies in the published literature, potentially because of subgroup effects. Here, we investigated the effect of minimally invasive cystectomy on LOS among different age groups. METHODS AND MATERIALS Adult patients who underwent cystectomy (open or minimally invasive) from January 1, 2012, to December 31, 2016, were identified from the National Surgical Quality Improvement Program database. Multivariable linear regression was used to evaluate the adjusted association between the surgical approach and LOS after stratifying patients by age (40-64, 65-79, and ≥80 years). A sensitivity analysis was performed after multiple imputation by using age as a continuous variable with a third-order polynomial term. RESULTS Of the 5,561 patients identified, 640 underwent minimally invasive cystectomy and 4,921 had open cystectomy. The unadjusted analysis showed that minimally invasive cystectomy was associated with a shorter mean LOS compared with the open approach (8.0 vs. 9.7 days; P < 0.001). The predicted difference in LOS between the 2 approaches was 0.72 days (95% confidence interval (CI), -0.28 to 1.72; P = 0.16) for patients aged 40 to 64 years, 1.48 days (95% CI, 0.73-2.23; P < 0.001) for 65 to 79 years, and 2.56 days (95% CI, 0.84-4.29; P = 0.01) for ≥80 years favoring the minimally invasive approach. The sensitivity analysis did not materially change the results. CONCLUSIONS Older patients may derive more LOS benefit from minimally invasive approaches than younger patients. Given the greater expense associated with the minimally invasive approach, an age-adapted strategy to using this technology may be reasonable.
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Affiliation(s)
- Kassem Faraj
- Department of Urology, Mayo Clinic Hospital, Phoenix, AZ
| | | | | | - Gail Blodgett
- Biostatistics, and Patient Collaborator, Mayo Clinic, Scottsdale, AZ
| | - David A Etzioni
- Department of Urology, Division of Colon and Rectal Surgery, Mayo Clinic Hospital, Phoenix, AZ
| | | | - Paul E Andrews
- Department of Urology, Mayo Clinic Hospital, Phoenix, AZ
| | - Erik P Castle
- Department of Urology, Mayo Clinic Hospital, Phoenix, AZ
| | | | - Mark D Tyson
- Department of Urology, Mayo Clinic Hospital, Phoenix, AZ.
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Ziegelmann MJ, Joseph JP, Glasgow AE, Tyson MD, Pak RW, Gazelka HM, Schatz AL, Leibovich BC, Habermann EB, Gettman MT. Wide Variation in Opioid Prescribing After Urological Surgery in Tertiary Care Centers. Mayo Clin Proc 2019; 94:262-274. [PMID: 30711124 DOI: 10.1016/j.mayocp.2018.08.035] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 07/09/2018] [Accepted: 08/06/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe postoperative opioid prescribing practices in a large cohort of patients undergoing urological surgery. PATIENTS AND METHODS We identified 11,829 patients who underwent 21 urological surgical procedures at 3 associated facilities from January 1, 2015, through December 31, 2016. After converting opioids to oral morphine equivalents (OMEs), prescribing patterns were compared within and across procedures. Subgroup analysis for opioid-naive patients (those without a history of long-term opioid use) was performed. Statistical analysis was utilized to evaluate variations based on demographic and perioperative/postoperative variables. RESULTS Of the 11,829 patients, 9229 (78.0%) were prescribed an opioid at discharge, and the median (interquartile range [IQR]) OME prescribed was 188 (150-225). The remaining 9253 patients (78.2%) were considered opioid naive. Striking variation in prescribing patterns was observed within and across surgical procedures. For instance, IQR ranges of 150 or greater were observed for open cystectomy (median, 300; IQR, 210-375], open radical nephrectomy (median, 300; IQR, 225-375), retroperitoneal node dissection (median, 300; IQR, 225-375), hand-assisted laparoscopic nephrectomy (median, 225; IQR, 150-300), and penile prosthesis (median, 225; IQR, 150-315). On multivariate analysis, younger age, cancer diagnosis, and inpatient hospitalization were associated with higher likelihood of receiving a highest-quartile OME prescription for opioid naive patients. Thirty-day refill rates varied from 1.6% to 25.9%. Interestingly, refill rates were higher in patients receiving more opioids at discharge. CONCLUSION The United States is facing an opioid epidemic, and physicians must take action. In this study, we found considerable variation in opioid prescribing patterns within and across surgical procedures. These data provide support for the development of standardized opioid prescribing guidelines for postoperative analgesia.
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Affiliation(s)
| | | | - Amy E Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Mayo Clinic, Rochester, MN
| | - Mark D Tyson
- Department of Urology, Mayo Clinic, Scottsdale, AZ
| | - Raymond W Pak
- Department of Urology, Mayo Clinic, Jacksonville, FL
| | - Halena M Gazelka
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | | | | | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Mayo Clinic, Rochester, MN
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Faba OR, Tyson MD, Artibani W, Bochner BH, Burkhard F, Gilbert SM, Kälble T, Madersbacher S, Seiler R, Skinner EC, Thalmann G, Thüroff J, Wiklund P, Hautmann R, Palou J. Update of the ICUD-SIU International Consultation on Bladder Cancer 2018: urinary diversion. World J Urol 2018; 37:85-93. [PMID: 30238399 DOI: 10.1007/s00345-018-2484-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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: 06/05/2018] [Accepted: 09/10/2018] [Indexed: 02/02/2023] Open
Abstract
PURPOSE To provide a comprehensive overview and update of the joint consultation of the International Consultation on Urological Diseases (ICUD) and Société Internationale d'Urologie on Bladder Cancer Urinary Diversion (UD). METHODS A detailed analysis of the literature was conducted reporting on the different modalities of UD. For this updated publication, an exhaustive search was conducted in PubMed for recent relevant papers published between October 2013 and August 2018. Via this search, a total of 438 references were identified and 52 of them were finally eligible for analysis. An international, multidisciplinary expert committee evaluated and graded the data according to the Oxford System of Evidence-based Medicine. RESULTS The incidence of early complications has been reported retrospectively in the range of 20-57%. Unfortunately, only a few randomized controlled studies exist within the field of UD. Consequently, almost all studies used in this report are of level 3-4 evidence including expert opinion based on "first principles" research. CONCLUSIONS Complications rates overall following RC and UD are significant, and when strict reporting criteria are incorporated, they are much higher than previously published. Complications can occur up to 20 years after surgery, emphasizing the need for lifelong follow-up. Progress has been made to prevent complications implementing robotic surgery and fast track protocols. Preoperative patient information, patient selection, surgical techniques, and careful postoperative follow-up are the cornerstones to achieve good results.
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Affiliation(s)
- Oscar Rodríguez Faba
- Urological Oncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, C/Cartagena, 340-350, 08025, Barcelona, Spain.
| | - Mark D Tyson
- Department of Urology, Mayo Clinic, Scottsdale, USA
| | - Walter Artibani
- Urology Clinic, Verona Integrated University Hospital, Verona, Italy
| | - Bernard H Bochner
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Fiona Burkhard
- Department of Urology, Inselspital Bern, Bern, Switzerland
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Tilman Kälble
- Urology and Pediatric Urology Clinic, Klinikum Fulda, Fulda, Germany
| | | | - Roland Seiler
- Uro-Oncology and Prostate Centre, Department of Urology, Inselspital Bern, Bern, Switzerland
| | - Ella C Skinner
- Urologic Oncology, Department of Urology, Stanford University, Stanford, USA
| | - George Thalmann
- Uro-Oncology and Prostate Centre, Department of Urology, Inselspital Bern, Bern, Switzerland
| | - Joachim Thüroff
- Department of Urology, University Clinic Mannheim, Mannheim, Germany
| | - Peter Wiklund
- Department of Urology, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Solna, Sweden
| | | | - Joan Palou
- Urological Oncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, C/Cartagena, 340-350, 08025, Barcelona, Spain
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Resnick MJ, Graves AJ, Thapa S, Gambrel R, Tyson MD, Lee D, Buntin MB, Penson DF. Medicare Accountable Care Organization Enrollment and Appropriateness of Cancer Screening. JAMA Intern Med 2018; 178:648-654. [PMID: 29554179 PMCID: PMC5876897 DOI: 10.1001/jamainternmed.2017.8087] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Despite rapid diffusion of Accountable Care Organizations (ACOs), whether ACO enrollment results in observable changes in cancer screening remains unknown. OBJECTIVE To determine whether Medicare Shared Savings Program (MSSP) ACO enrollment changes the appropriateness of screening for breast, colorectal, and prostate cancers. DESIGN, SETTING, AND PARTICIPANTS For this population-based analysis of Medicare beneficiaries, we used Medicare data from 2007 through 2014 and evaluated changes in screening associated with ACO enrollment using differences-in-differences (DD) analyses. We then performed difference-in-difference-in-differences (DDD) analyses to determine whether observed changes in cancer screening associated with ACO enrollment were different across strata of appropriateness, defined using age (65-74 years vs ≥75 years) and predicted survival (top vs bottom quartile). MAIN OUTCOMES AND MEASURES Rates of breast, colorectal, and prostate cancer screening measured yearly as a proportion of eligible Medicare beneficiaries undergoing relevant screening services. RESULTS Among Medicare beneficiaries, comprising 39 218 652 person-years before MSSP enrollment and 17 252 345 person-years after MSSP enrollment, breast cancer screening declined among both ACO (42.7% precontract, 38.1% postcontract) and non-ACO (37.3% precontract, 34.1% postcontract) populations. The adjusted rate of decline (DD) in the ACO population exceeded the non-ACO population by 0.79% (P < .001). This decline was most pronounced among elderly women (-2.1%), with minimal observed change among younger women (-0.26%). Baseline colorectal cancer screening rates were lower than those for breast cancer among both ACO (10.1% precontract, 10.3% postcontract) and non-ACO (9.2% precontract, 9.1% postcontract) populations. We observed an adjusted 0.24% (P = .03) increase in screening associated with ACO enrollment, most pronounced among younger Medicare beneficiaries (0.36%). For breast and colorectal cancer, we observed statistically significant differences in estimates of effect between age strata, suggesting that the ACO effect on cancer screening is mediated by age (DDD for both P < .001). Prostate cancer screening declined among ACO (35.1% precontract, 28.5% postcontract) and non-ACO (31.2% precontract, 25.7% postcontract) populations. The adjusted rate of decline in the ACO population exceeded that of the non-ACO population by 1.2%. We observed no difference in estimate of effect between age strata, suggesting that the ACO-mediated changes in prostate cancer screening are similar among younger and elderly men. Results characterizing appropriateness with predicted survival mirrored those when stratified by age. CONCLUSIONS AND RELEVANCE Medicare Shared Savings Program ACO enrollment is associated with more appropriate breast and colorectal screening, although the magnitude of the observed ACO effect is modest in the early ACO experience.
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Affiliation(s)
- Matthew J Resnick
- Departments of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Departments of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research and Education Center, Tennessee Valley VA Health Care System, Nashville
| | - Amy J Graves
- Departments of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunita Thapa
- Departments of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert Gambrel
- Departments of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark D Tyson
- Department of Urology, Mayo Clinic, Scottsdale, Arizona
| | - Daniel Lee
- Departments of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melinda B Buntin
- Departments of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David F Penson
- Departments of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Departments of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research and Education Center, Tennessee Valley VA Health Care System, Nashville
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Tyson MD, Chang SS. Optimal Surveillance Strategies After Surgery for Renal Cell Carcinoma. J Natl Compr Canc Netw 2018; 15:835-840. [PMID: 28596262 DOI: 10.6004/jnccn.2017.0102] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 03/06/2017] [Indexed: 11/17/2022]
Abstract
One in 5 patients who undergo surgical resection for clinically localized renal cell carcinoma (RCC) develop local and/or distant recurrences which, when detected early, may be amenable to salvage local and systemic therapies. When considering that approximately half of these recurrences will occur during the first 2 years, a clear rationale exists for optimizing surveillance strategies after surgery. Although there is a notable dearth of high-quality data on this subject, clinical principles can guide clinicians as they attempt to balance the burden of surveillance strategies with potential clinical benefit. The objective of this review is to summarize the evidence regarding optimal surveillance protocols after surgery for RCC. We provide an overview of the rationale supporting surveillance after surgery, a summary of the American Urological Association and NCCN guidelines, reasons against routine long-term surveillance, surveillance costs, and ancillary issues, such as the utility of bone scan, PET/CT scan, and surveillance after thermoablation.
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Affiliation(s)
- Mark D Tyson
- From the Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sam S Chang
- From the Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Abstract
Approximately 1 in 5 new cases of clinically localized bladder cancer is muscle invasive and requires the patient to choose from 1 of 2 prevailing options for treatment: radical cystectomy or radiation to the bladder. However, these treatments are associated with detrimental effects on patient well-being and quality of life, particularly with respect to functional independence, urinary and sexual function, social and emotional health, body image, and psychosocial stress. Compared with the literature on other malignancies like breast or prostate cancer, high-quality studies evaluating the effects of bladder cancer treatment on quality of life are lacking.
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Affiliation(s)
- Mark D Tyson
- Department of Urology, Mayo Clinic Arizona, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.
| | - Daniel A Barocas
- Department of Urologic Surgery, Vanderbilt University Medical Center, A1302 Medical Center North, Nashville, TN 37203, USA
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Bhalla RG, Wang L, Chang SS, Tyson MD. Association between Preoperative Albumin Levels and Length of Stay after Radical Cystectomy. J Urol 2017; 198:1039-1045. [DOI: 10.1016/j.juro.2017.05.066] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Rohan G. Bhalla
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Li Wang
- Department of Biostatistics, Nashville, Tennessee
| | - Sam S. Chang
- Department of Urologic Surgery, Nashville, Tennessee
| | - Mark D. Tyson
- Department of Urologic Surgery, Nashville, Tennessee
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Tyson MD, Graves AJ, O'Neil B, Barocas DA, Chang SS, Penson DF, Resnick MJ. Urologist-Level Correlation in the Use of Observation for Low- and High-Risk Prostate Cancer. JAMA Surg 2017; 152:27-34. [PMID: 27653425 DOI: 10.1001/jamasurg.2016.2907] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The reporting of individual urologist rates of observation for localized prostate cancer may be a valuable performance measure with important downstream implications for patient and payer stakeholder groups. However, few studies have examined the urologist-level variation in the use of observation across all risk strata of prostate cancer. Objectives To measure variation in the use of observation at the urologist level by disease risk strata and to evaluate the association between the urologist-level rates of observation for men with low-risk and high-risk prostate cancer. Design, Setting, and Participants With the use of linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data, a population-based study of men diagnosed with prostate cancer from January 1, 2004, to December 31, 2009, was performed in SEER catchment areas of the United States. A total of 57 639 men with prostate cancer with 1884 diagnosing urologists were identified. Data were analyzed from October 1 to December 31, 2015. Main Outcomes and Measures The main outcome was observation, which is defined as the absence of definitive treatment within 1 year of diagnosis. In each risk stratum, a multivariable mixed-effects model was fit to characterize associations between observation and selected patient characteristics. From these models, the estimated probability of observation was calculated for each urologist within each risk stratum, and the association between the physician-level estimated rates of observation for low-risk and high-risk disease was assessed. Results Among the 57 639 men included in the study, the estimated probability of observation for low-risk disease varied impressively (mean, 27.8%; range, 5.1%-71.2%) at the individual urologist level. Considerably less urologist-level variation was seen in the use of observation for intermediate-risk disease (11.1%; range, 4.8%-31.5%) and high-risk disease (5.8%; range, 3.2%-16.5%). Furthermore, the estimated rates of observation for low- and high-risk disease were correlated at the urologist level (Spearman ρ = 0.17; P < .001). A comparable correlation was likewise observed among urologists with high-volume prostate cancer practices (Spearman ρ = 0.24; P < .001). Conclusions and Relevance Considerable urologist-level variation is seen in the use of observation for men with low-risk prostate cancer. More important, the use of observation for low-risk and high-risk patients with prostate cancer is correlated at the urologist level. This study reveals the strikingly variable use of observation among US urologists and establishes a framework for the use of urologist-level treatment signatures as a quality measure in the emerging value-based health care environment.
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Affiliation(s)
- Mark D Tyson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amy J Graves
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brock O'Neil
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel A Barocas
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sam S Chang
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David F Penson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee2Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee3Geriatric Research and Educational Center, Veterans Affairs Tennessee Valley Health Care System, Nashville
| | - Matthew J Resnick
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee2Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee3Geriatric Research and Educational Center, Veterans Affairs Tennessee Valley Health Care System, Nashville
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Tyson MD, Ark J, Gregg JR, Johnsen NV, Kappa SF, Lee DJ, Smith JA. The Null Effect of Bladder Neck Size on Incontinence Outcomes after Radical Prostatectomy. J Urol 2017; 198:1404-1408. [PMID: 28655528 DOI: 10.1016/j.juro.2017.06.084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE We sought to determine whether bladder neck size is associated with incontinence scores after robot-assisted laparoscopic radical prostatectomy. MATERIALS AND METHODS Consecutive eligible patients undergoing robot-assisted laparoscopic radical prostatectomy between July 19 and December 28, 2016 were enrolled in a prospective, longitudinal, observational cohort study. The primary outcome was patient reported urinary incontinence on the EPIC (Expanded Prostate Cancer Index Composite) scale 6 and 12 weeks postoperatively. The relationship between the EPIC score of urinary incontinence and bladder neck size was evaluated by multiple regression. Predicted EPIC scores for incontinence were displayed graphically after using restricted cubic splines to model bladder neck size. RESULTS A total of 107 patients were enrolled. The response rate was 98% and 87% at 6 and 12 weeks, respectively. Bladder neck size was not significantly associated with incontinence scores at 6 and 12 weeks. Comparing the 90th percentile for bladder neck size (18 mm) with the 10th percentile (7 mm) revealed no significant difference in adjusted EPIC scores for incontinence at 6 weeks (β coefficient 0.88, 95% CI -10.92-12.68, p = 0.88) or at 12 weeks (β coefficient 5.80, 95% CI -7.36-18.97, p = 0.39). CONCLUSIONS These findings question the merit of creating an extremely small bladder neck during robot-assisted laparoscopic radical prostatectomy. We contend that doing so increases the risk of positive margins at the bladder neck without facilitating early recovery of continence.
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Affiliation(s)
- Mark D Tyson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Urology, Mayo Clinic Hospital (MDT), Phoenix, Arizona.
| | - Jacob Ark
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Urology, Mayo Clinic Hospital (MDT), Phoenix, Arizona
| | - Justin R Gregg
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Urology, Mayo Clinic Hospital (MDT), Phoenix, Arizona
| | - Niels V Johnsen
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Urology, Mayo Clinic Hospital (MDT), Phoenix, Arizona
| | - Stephen F Kappa
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Urology, Mayo Clinic Hospital (MDT), Phoenix, Arizona
| | - Daniel J Lee
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Urology, Mayo Clinic Hospital (MDT), Phoenix, Arizona
| | - Joseph A Smith
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Urology, Mayo Clinic Hospital (MDT), Phoenix, Arizona
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Barocas DA, Alvarez J, Resnick MJ, Koyama T, Hoffman KE, Tyson MD, Conwill R, McCollum D, Cooperberg MR, Goodman M, Greenfield S, Hamilton AS, Hashibe M, Kaplan SH, Paddock LE, Stroup AM, Wu XC, Penson DF. Association Between Radiation Therapy, Surgery, or Observation for Localized Prostate Cancer and Patient-Reported Outcomes After 3 Years. JAMA 2017; 317:1126-1140. [PMID: 28324093 PMCID: PMC5782813 DOI: 10.1001/jama.2017.1704] [Citation(s) in RCA: 228] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Importance Understanding the adverse effects of contemporary approaches to localized prostate cancer treatment could inform shared decision making. Objective To compare functional outcomes and adverse effects associated with radical prostatectomy, external beam radiation therapy (EBRT), and active surveillance. Design, Setting, and Participants Prospective, population-based, cohort study involving 2550 men (≤80 years) diagnosed in 2011-2012 with clinical stage cT1-2, localized prostate cancer, with prostate-specific antigen levels less than 50 ng/mL, and enrolled within 6 months of diagnosis. Exposures Treatment with radical prostatectomy, EBRT, or active surveillance was ascertained within 1 year of diagnosis. Main Outcomes and Measures Patient-reported function on the 26-item Expanded Prostate Cancer Index Composite (EPIC) 36 months after enrollment. Higher domain scores (range, 0-100) indicate better function. Minimum clinically important difference was defined as 10 to 12 points for sexual function, 6 for urinary incontinence, 5 for urinary irritative symptoms, 5 for bowel function, and 4 for hormonal function. Results The cohort included 2550 men (mean age, 63.8 years; 74% white, 55% had intermediate- or high-risk disease), of whom 1523 (59.7%) underwent radical prostatectomy, 598 (23.5%) EBRT, and 429 (16.8%) active surveillance. Men in the EBRT group were older (mean age, 68.1 years vs 61.5 years, P < .001) and had worse baseline sexual function (mean score, 52.3 vs 65.2, P < .001) than men in the radical prostatectomy group. At 3 years, the adjusted mean sexual domain score for radical prostatectomy decreased more than for EBRT (mean difference, -11.9 points; 95% CI, -15.1 to -8.7). The decline in sexual domain scores between EBRT and active surveillance was not clinically significant (-4.3 points; 95% CI, -9.2 to 0.7). Radical prostatectomy was associated with worse urinary incontinence than EBRT (-18.0 points; 95% CI, -20.5 to -15.4) and active surveillance (-12.7 points; 95% CI, -16.0 to -9.3) but was associated with better urinary irritative symptoms than active surveillance (5.2 points; 95% CI, 3.2 to 7.2). No clinically significant differences for bowel or hormone function were noted beyond 12 months. No differences in health-related quality of life or disease-specific survival (3 deaths) were noted (99.7%-100%). Conclusions and Relevance In this cohort of men with localized prostate cancer, radical prostatectomy was associated with a greater decrease in sexual function and urinary incontinence than either EBRT or active surveillance after 3 years and was associated with fewer urinary irritative symptoms than active surveillance; however, no meaningful differences existed in either bowel or hormonal function beyond 12 months or in in other domains of health-related quality-of-life measures. These findings may facilitate counseling regarding the comparative harms of contemporary treatments for prostate cancer.
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Affiliation(s)
- Daniel A. Barocas
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - JoAnn Alvarez
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew J. Resnick
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tatsuki Koyama
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Karen E. Hoffman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mark D. Tyson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ralph Conwill
- Prostate Cancer Patient Advocate, Vanderbilt Ingram Cancer Center, Nashville, Tennessee
| | - Dan McCollum
- Prostate Cancer Patient Advocate, Vanderbilt Ingram Cancer Center, Nashville, Tennessee
| | - Matthew R. Cooperberg
- Department of Urology, University of California, San Francisco Medical Center, San Francisco, California
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Emory University, Atlanta, Georgia
| | - Sheldon Greenfield
- Center for Health Policy Research and Department of Medicine, University of California, Irvine, Irvine, California
| | - Ann S. Hamilton
- Department of Preventative Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mia Hashibe
- Department of Family and Preventative Medicine, University of Utah, Salt Lake City, Utah
| | - Sherrie H. Kaplan
- Health Policy Research Institute, University of California, Irvine, Irvine, California
| | - Lisa E. Paddock
- Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey
| | - Antoinette M. Stroup
- Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey
| | - Xiao-Cheng Wu
- School of Public Health, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - David F. Penson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Tennessee Valley Veterans Administration Health System, Nashville, TN
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Abdul-Muhsin HM, Tyson MD, Stern KL, Nunez-Nateras RA, Humphreys MR. The impact of training on the perioperative and intermediate functional outcomes after holmium laser enucleation of the prostate. Can J Urol 2016; 23:8557-8563. [PMID: 27995851] [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: 06/06/2023]
Abstract
INTRODUCTION To systemically measure the impact of trainees' participation on the perioperative and functional outcomes after holmium laser enucleation of the prostate (HoLEP). MATERIALS AND METHODS Benign prostatic hyperplasia patients who underwent HoLEP at our department between January 2007 and January 2013 were classified based on trainee's level. Perioperative outcomes and complications were collected. Functional outcomes were assessed using the Sexual Health Inventory for Men (SHIM), International Prostate Symptom Score (IPSS), and International Continence Society-Short Form (ICSmaleSF) questionnaires. Voiding and incontinence domains of ICSmaleSF were assessed separately. Patients were divided into group 1 if no trainee participated in the operation, group 2 if a senior trainee performed the operation, and group 3 if a junior trainee participated in the operation. The patient's baseline characteristics, complications, and perioperative outcomes were compared. RESULTS There were no differences in the baseline characteristics. There were significant differences in overall operative and enucleation time (p = 0.0186, p = 0.0047, respectively) with shorter times noticed with more experienced operators. There were no differences in resected tissue weight, hemoglobin change, and transfusion rates. Postoperatively, all patients had a similar length of stay and catheterization. Complications (graded by Clavien grading system) were not different. All patients were followed up at regular intervals starting at 6 weeks, 3 months , 6 months, 1 year, and every year after that and there were no differences in flow rates or post void residual volumes at any time point. There were no differences in SHIM, IPSS, and ICSmale voiding scale among the groups. However, ICSmale continence scale was significantly different where the highest score seen in group 2. CONCLUSION Trainee participation in HoLEP in a controlled training environment does not compromise the safety of the procedure.
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Tyson MD, Penson DF. 'Killing two birds with one stone': patient-reported quality-of-life outcomes from the Prostate Testing for Cancer and Treatment (ProtecT) trial. BJU Int 2016; 118:844-845. [PMID: 27870363 DOI: 10.1111/bju.13673] [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: 12/01/2022]
Affiliation(s)
- Mark D Tyson
- Department of Urologic Surgery, Veterans Affairs Tennessee Valley Health Care System, Nashville, TN, USA
| | - David F Penson
- Department of Urologic Surgery, Veterans Affairs Tennessee Valley Health Care System, Nashville, TN, USA.,Department of Health Policy, Vanderbilt University Medical Center, Veterans Affairs Tennessee Valley Health Care System, Nashville, TN, USA.,Department of Geriatric, Research, and Educational Center, Veterans Affairs Tennessee Valley Health Care System, Nashville, TN, USA
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Tyson MD, Alvarez J, Koyama T, Hoffman KE, Resnick MJ, Wu XC, Cooperberg MR, Goodman M, Greenfield S, Hamilton AS, Hashibe M, Paddock LE, Stroup A, Chen VW, Penson DF, Barocas DA. Racial Variation in Patient-Reported Outcomes Following Treatment for Localized Prostate Cancer: Results from the CEASAR Study. Eur Urol 2016; 72:307-314. [PMID: 27816300 DOI: 10.1016/j.eururo.2016.10.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 10/20/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Relatively little is known about the relationship between race/ethnicity and patient-reported outcomes after contemporary treatments for localized prostate cancer. OBJECTIVE To test the hypothesis that treatment-related changes in urinary, bowel, sexual, and hormonal function vary by race/ethnicity. DESIGN, SETTING, AND PARTICIPANTS The Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) study is a prospective, population-based, observational study that enrolled 3708 men diagnosed with localized prostate cancer in 2011-2012. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Patient-reported disease-specific function was measured using the 26-item Expanded Prostate Index Composite (EPIC) at baseline and 6 and 12 mo after enrollment. Mean treatment differences in function were compared by race using risk-adjusted generalized estimating equations. RESULTS AND LIMITATIONS While all race/ethnic groups reported considerable declines in scores for urinary incontinence after radical prostatectomy (RP) when compared to active surveillance, African-American men reported a greater difference than white men did (adjusted difference-in-differences 8.4 points, 95% confidence interval 2.0-14.8; p=0.01). No difference in bother scores was noted and the overall proportion of explained variation attributable to race/ethnicity was relatively small in comparison to primary treatment and baseline function. No clinically significant racial variation was noted for the sexual, bowel, irritative voiding, or hormone domains. Limitations include the lack of well-established thresholds for clinical significance using the EPIC instrument. CONCLUSION While these data demonstrate that incontinence at 1 yr after RP may be worse for African-American compared to white men, the difference appears to be modest overall. Treatment selection and baseline function explain a much greater proportion of the variation in function after treatment. PATIENT SUMMARY We observed that the effect of treatment for prostate cancer on patient-reported function did not vary dramatically by race/ethnicity. Compared to white men, African-American men experienced a somewhat more pronounced decline in urinary continence after radical prostatectomy, but the corresponding changes in bother scores were not significantly different between the two groups.
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Affiliation(s)
- Mark D Tyson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - JoAnn Alvarez
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Tatsuki Koyama
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Karen E Hoffman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew J Resnick
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, USA; The Geriatric Research, Education, and Clinical Center, Tennessee Valley Veterans Affairs Health Care System, Nashville, TN, USA
| | - Xiao-Cheng Wu
- School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Matthew R Cooperberg
- Department of Urology, University of California, San Francisco Medical Center, San Francisco, CA, USA
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sheldon Greenfield
- Center for Health Policy Research and Department of Medicine, University of California, Irvine, CA, USA
| | - Ann S Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Mia Hashibe
- Department of Family and Preventive Medicine and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Lisa E Paddock
- Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
| | - Antoinette Stroup
- Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
| | - Vivien W Chen
- School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - David F Penson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; The Geriatric Research, Education, and Clinical Center, Tennessee Valley Veterans Affairs Health Care System, Nashville, TN, USA
| | - Daniel A Barocas
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Sohn W, Graves AJ, Tyson MD, O'Neil B, Chang SS, Ni S, Barocas DA, Penson DF, Resnick MJ. An Empiric Evaluation of the Effect of Variation in Intensity of Followup for Surgically Treated Renal Neoplasms on Cancer Specific Survival. J Urol 2016; 197:37-43. [PMID: 27575607 DOI: 10.1016/j.juro.2016.08.094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2016] [Indexed: 01/11/2023]
Abstract
PURPOSE Followup protocols after the surgical management of renal cell carcinoma lack clear evidence linking the intensity of imaging surveillance to improved outcomes. In this context we characterized the relationship between surveillance imaging intensity and cancer specific survival. MATERIALS AND METHODS Using SEER-Medicare data we identified 7,603 men with renal cell carcinoma treated surgically between 2004 and 2009. Multivariable negative binomial regression analysis was performed to assess the relationship between patient level characteristics and the variation in imaging intensity. We modeled the association between kidney cancer specific mortality and imaging intensity using Fine and Gray proportional subdistribution hazards regression with other cause death treated as a competing risk for 2 separate followup periods (15 and 36 months). RESULTS More than 40% of patients in the short interval cohort and more than 50% in the intermediate interval group underwent no chest imaging during the evaluated survivorship period. More than 30% of patients in both followup periods had no abdominal imaging tests performed. Overall, followup imaging did not appear to confer an improvement in disease specific survival compared to undergoing no imaging in the 2 survivorship periods. CONCLUSIONS There remains considerable variation in the posttreatment surveillance regimen for patients with renal cell carcinoma in the United States. More importantly, this study raises important questions regarding the link between posttreatment surveillance imaging and survival.
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Affiliation(s)
- William Sohn
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amy J Graves
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark D Tyson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brock O'Neil
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sam S Chang
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shenghua Ni
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel A Barocas
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David F Penson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center, Tennessee Valley VA Health Care System, Nashville, Tennessee
| | - Matthew J Resnick
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center, Tennessee Valley VA Health Care System, Nashville, Tennessee.
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Tyson MD, Bryce A. The Effect of Enzalutamide and Bicalutamide on Patient-reported Quality of Life Outcomes: Results from the TERRAIN Study. Eur Urol 2016; 71:543-544. [PMID: 27544580 DOI: 10.1016/j.eururo.2016.08.017] [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] [Received: 08/03/2016] [Accepted: 08/08/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Mark D Tyson
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Alan Bryce
- Division of Hematology and Oncology, Mayo Clinic, Phoenix, AZ, USA
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