Contemporary risk of biochemical recurrence after radical prostatectomy in the active surveillance era

OBJECTIVES

To assess whether contemporary risks of biochemical recurrence (BCR) after radical prostatectomy (RP) in the AS era differ from historical estimates due to changes in tumor risk case mix and improvements in risk stratification.

MATERIALS AND METHODS

We sampled 6,682 men who underwent RP for clinically localized disease between 2000 and 2017 from the VA SEARCH database. Kaplan Meier analysis was used to calculate incidence of BCR before and after 2010 overall and within tumor risk subgroups. Multivariable Cox proportional hazard regression analysis including an interaction term between era and tumor risk was used to compare risk of BCR before and after 2010 overall and across tumor risk subgroups.

RESULTS

About 3,492 (52%) and 3,190 (48%) men underwent RP before and after 2010, respectively. In a limited multivariable model excluding tumor risk, overall BCR risk was higher post-2010 vs. pre-2010 (HR: 1.15, 95%CI: 1.05-1.25; 40% vs 36% at 8 years post-RP). However, this effect was eliminated after correcting for tumor risk (HR: 0.95, 95%CI: 0.87-1.04), suggesting that differences in tumor risk between eras mediated the change. Yet, within tumor-risk subgroups, BCR risk was significantly lower for favorable intermediate-risk (HR: 0.76, 95%CI:0.60-0.96) and unfavorable intermediate-risk PC (HR: 0.78, 95%CI: 0.67-0.90), but significantly higher for high-risk PC (HR: 1.22, 95%CI: 1.07-1.38) in the post-2010 era. 8-year risks of BCR in the post-2010 era were 21% (95%CI: 16%-25%), 25% (95%CI: 20%-30%), 41% (95%CI: 37%-46%), and 60% (95%CI: 56%-64%) for low-, FIR-, UIR-, and high-risk disease, respectively. Limitations include limited long-term follow-up in the post-2010 subgroup.

CONCLUSIONS

Overall BCR risk has increased in the AS era, driven by a higher risk case mix and increased BCR risk among high-risk patients. Physicians should quote contemporary estimates of BCR when counseling patients.

Malpractice Trends Involving Active Surveillance Across Cancers

OBJECTIVE

To characterize malpractice trends related to active surveillance (AS) as a treatment strategy across cancers.

BACKGROUND

Active surveillance is increasingly considered a viable management strategy for low-risk cancers. Since a subset of AS cases will progress, metastasize, or exhibit cancer-related mortality, a significant barrier to implementation is the perceived risk of litigation from missing the window for cure. Data on malpractice trends across cancers are lacking.

METHODS

Westlaw Edge and LexisNexis Advance databases were searched from 1990 to 2022 for malpractice cases involving active surveillance in conjunction with thyroid cancer, prostate cancer, kidney cancer, breast cancer, or lymphoma. Queries included unpublished cases, trial orders, jury verdicts, and administrative decisions. Data were compiled on legal allegations, procedures performed, and verdicts or settlements rendered.

RESULTS

Five prostate cancer cases were identified that pertained to active surveillance. Two cases involved alleged deliberate indifference from AS as a management strategy but were ruled as following the appropriate standard of care. In contrast, 3 cases involved alleged physician negligence for not explicitly recommending AS as a treatment option after complications from surgery occurred. All cases showed documented informed consent for AS, leading to defense verdicts in favor of the physicians. No cases of AS-related malpractice were identified for other cancer types.

CONCLUSIONS

To date, no evidence of successful malpractice litigation for active surveillance in cancer has been identified. Given the legal precedent detailed in the identified cases and increasing support across national guidelines, active surveillance represents a sound management option in appropriate low-risk cancers, with no increased risk of medicolegal exposure.

Use of Persuasive Language in Communication of Risk during Prostate Cancer Treatment Consultations

BACKGROUND

Physician treatment preference may influence how risks are communicated in prostate cancer consultations. We identified persuasive language used when describing cancer prognosis, life expectancy, and side effects in relation to a physician's recommendation for aggressive (surgery/radiation) or nonaggressive (active surveillance/watchful waiting) treatment.

METHODS

A qualitative analysis was performed on transcribed treatment consultations of 40 men with low- and intermediate-risk prostate cancer across 10 multidisciplinary providers. Quotes pertaining to cancer prognosis, life expectancy, and side effects were randomized. Coders predicted physician treatment recommendations from isolated blinded quotes. Testing characteristics of consensus predictions against the physician's treatment recommendation were reported. Coders then identified persuasive strategies favoring aggressive/nonaggressive treatment for each quote. Frequencies of persuasive strategies favoring aggressive/nonaggressive treatment were reported. Logistic regression quantified associations between persuasive strategies and physician treatment recommendations.

RESULTS

A total of 496 quotes about cancer prognosis (n = 127), life expectancy (n = 51), and side effects (n = 318) were identified. The accuracy of predicting treatment recommendation based on individual quotes containing persuasive language (n = 256/496, 52%) was 91%. When favoring aggressive treatment, persuasive language downplayed side effect risks and amplified cancer risk (recurrence, progression, or mortality). Significant predictors (P < 0.05) of aggressive treatment recommendation included favorable side effect interpretation, downplaying side effects, and long time horizon for cancer risk due to longevity. When favoring nonaggressive treatment, persuasive language amplified side effect risks and downplayed cancer risk. Significant predictors of nonaggressive treatment recommendation included unfavorable side effect interpretation, favorable interpretation of cancer risk, and short time horizon for cancer risk due to longevity.

CONCLUSIONS

Physicians use persuasive language favoring their preferred treatment, regardless of whether their recommendation is appropriate.

IMPLICATIONS

Clinicians should quantify risk so patients can judge potential harm without solely relying on persuasive language.

HIGHLIGHTS

Physicians use persuasive language favoring their treatment recommendation when communicating risks of prostate cancer treatment, which may influence a patient's treatment choice.Coders predicted physician treatment recommendations based on isolated, randomized quotes about cancer prognosis, life expectancy, and side effects with 91% accuracy.Qualitative analysis revealed that when favoring nonaggressive treatment, physicians used persuasive language that amplified side effect risks and downplayed cancer risk. When favoring aggressive treatment, physicians did the opposite.Providers should be cognizant of using persuasive strategies and aim to provide quantified assessments of risk that are jointly interpreted with the patient so that patients can make evidence-based conclusions regarding risks without solely relying on persuasive language.

High-Resolution Diffusion-Weighted Imaging to Detect Changes in Tumor Size and ADC, and Predict Adverse Biopsy Histology During Prostate Cancer Active Surveillance

PURPOSE

Majority of men with low-risk prostate cancer can be managed with active surveillance (AS). This study evaluates a high-resolution diffusion-weighted imaging (HR-DWI) technique to predict adverse biopsy histology (AH), defined as Gleason score >=7 on any biopsy or >=3 increase in number of positive biopsy cores on systematic biopsies. We test the hypothesis that high grade disease and progressing disease undergo subtle changes during even short intervals that can be detected by HR-DWI.

PATIENTS AND METHODS

In a prospective clinical trial, serial multiparametric MRIs, incorporating HR-DWI and standard DWI (S-DWI) were performed approximately 12 months apart prior to prostate biopsy (n=59). HR-DWI, which uses reduced field-of-view and motion compensation techniques, was compared to S-DWI.

RESULTS

HR-DWI had a 3-fold improvement in special resolution compared with S-DWI as confirmed using imaging phantoms. For detecting AH, multi-parametric MRI using HR-DWI had a sensitivity of 75% and specificity of 83.9%, and MRI using S-DWI had a sensitivity of 71.4% and specificity of 54.8%. The area under the curve for HR-DWI was significantly higher (0.794 vs 0.631, p=0.014). Secondary analyses of univariable predictors of AH showed tumor size increase (OR 16.8, 95% CI 4.06-69.48, p<0.001) and apparent diffusion coefficient (ADC) decrease (OR 5.06, 95% CI 1.39-18.38, p=0.014) on HR-DWI were significant predictors of AH.

CONCLUSION

HR-DWI outperforms S-DWI in predicting AH. Patient with AH have tumors that change in size and ADC that could be detected using HR-DWI. Future studies with longer follow-up should assess HR-DWI for predicting disease progression during AS.

Variation in communication of side effects in prostate cancer treatment consultations

BACKGROUND

Effective communication of treatment side effects (SE) is critical for shared decision-making (SDM) in localized prostate cancer. We sought to qualitatively characterize how physicians communicate SE in consultations.

METHODS

We transcribed 50 initial prostate cancer treatment consultations across nine multidisciplinary providers (Urologists, Radiation Oncologists, Medical Oncologists) at our tertiary referral, academic center. Coders identified quotes describing SE and used an inductive approach to establish a hierarchy for granularity of communication: (1) not mentioned, (2) name only, (3) generalization("high"), (4) average incidence without timepoint, (5) average incidence with timepoint, and (6) precision estimate. We reported the most granular mode of communication for each SE throughout the consultation overall and across specialty and tumor risk.

RESULTS

Among consultations discussing surgery (n = 40), erectile dysfunction (ED) and urinary incontinence (UI) were omitted in 15% and 12%, not quantified (name only or generalization) in 47% and 30%, and noted as average incidence without timeline in 8% and 8%, respectively. In only 30% and 49% were ED and UI quantified with timeline (average incidence with timeline or precision estimate), respectively. Among consultations discussing radiation (n = 36), irritative urinary symptoms, ED, and other post-radiotherapy SE were omitted in 22%, 42%, and 64-67%, not quantified in 61%, 33%, and 23-28%, and noted as average incidence without timeline in 8%, 22%, and 6-8%, respectively. In only 3-8% were post-radiotherapy SE quantified with timeline. Specialty concordance (but not tumor risk) was associated with higher granularity of communication, though physicians frequently failed to quantify specialty-concordant SE.

CONCLUSIONS

SE was often omitted, not quantified, and/or lacked a timeline in treatment consultations in our sample. Physicians should articulate, quantify, and assign a timeline for SE to optimize SDM.

Validation of the prostate cancer comorbidity index in predicting cause-specific mortality in men undergoing radical prostatectomy

PURPOSE

Accurate prediction of competing risks of mortality remains a key component of prostate cancer treatment decision-making. We sought to validate the Prostate Cancer Comorbidity Index (PCCI) score for predicting other-cause mortality (OCM) and cancer outcomes in men undergoing radical prostatectomy (RP).

MATERIALS AND METHODS

We sampled 4857 men with prostate cancer treated with RP in the VA from 2000-2018. Risks of OCM, 90-day all-cause mortality (ACM), prostate cancer-specific mortality, metastasis, and biochemical recurrence by PCCI score were assessed using Cox proportional hazards and logistic regression. We compared prediction of 90-day ACM between PCCI and the American Society of Anesthesiology (ASA) score, a validated predictor of short-term mortality.

RESULTS

Over median follow-up of 6.7 years (IQR 3.7-10.3), there was a stepwise increase in risk of OCM with higher PCCI score, with hazards (95%CI) of 1.53 (1.14-2.04), 2.11 (1.55-2.88), 2.36 (1.68-3.31), 3.61 (2.61-4.98), and 4.99 (3.58-6.96) for PCCI 1-2, 3-4, 5-6, 7-9, and 10 + (vs. 0), respectively. Projected 10-year cumulative incidence of OCM was 8%, 12%, 16%, 19%, 26%, and 32% for scores of 0, 1-2, 3-4, 5-6, 7-9, and 10+ , respectively. Men with PCCI 7+ had greater odds of 90-day ACM (OR 3.48, 95%CI 1.26-9.63) while men with higher ASA did not. Higher PCCI score was associated with worse cancer outcomes, with the highest categories driving the associations.

CONCLUSIONS

The PCCI is a robust measure of short- and long-term OCM after RP, validated for use in clinical care and health services research focusing on surgical patient populations.

Impact of Asian Race on Prognosis in De Novo Metastatic Prostate Cancer

BACKGROUND

Little is known about the impact of Asian race on the long-term survival outcomes of males with de novo metastatic prostate cancer (PCa). Understanding racial disparities in survival is critical for accurate prognostic risk stratification and for informing the design of multiregional clinical trials.

METHODS

This multiple-cohort study included individual patient-level data for males with de novo metastatic PCa from the following 3 cohorts: LATITUDE clinical trial data (n=1,199), the SEER program (n=15,476), and the National Cancer Database (NCDB; n=10,366). Primary outcomes were overall survival (OS) in LATITUDE and NCDB and OS and cancer-specific survival in SEER.

RESULTS

Across all 3 cohorts, Asian patients diagnosed with de novo metastatic PCa had better survival than white patients. In LATITUDE, median OS was significantly longer in Asian versus white patients in the androgen deprivation therapy (ADT) + abiraterone + prednisone group (not reached vs 43.8 months; hazard ratio [HR], 0.45; 95% CI, 0.28-0.73; P=.001) as well as in the ADT + placebo group (57.6 vs 32.7 months; HR, 0.51; 95% CI, 0.33-0.78; P=.002). In SEER, among all patients diagnosed with de novo metastatic PCa, median OS was significantly longer in Asian versus white males (49 vs 39 months; HR, 0.76; 95% CI, 0.68-0.84; P<.001). Among those who received chemotherapy, Asian patients again had longer OS (52 vs 42 months; HR, 0.71; 95% CI, 0.52-0.96; P=.025). Using data on cancer-specific survival in SEER resulted in similar conclusions. In NCDB, Asian patients also had longer OS than white patients in aggregate and in subgroups of males treated with ADT or chemotherapy (aggregate: 38 vs 26 months; HR, 0.72; 95% CI, 0.62-0.83; P<.001; ADT subgroup: 41 vs 26 months; HR, 0.71; 95% CI, 0.60-0.84; P<.001; chemotherapy subgroup: 34 vs 25 months; HR, 0.67; 95% CI, 0.57-0.78; P<.001).

CONCLUSIONS

Asian males have better OS and cancer-specific survival than white males with metastatic PCa across different treatment regimens. This should be considered when assessing prognosis and in designing multinational clinical trials.

Disparities in COVID-19 Disease Incidence by Income and Vaccination Coverage - 81 Communities, Los Angeles, California, July 2020-September 2021

COVID-19 has disproportionately affected socially vulnerable communities characterized by lower income, lower education attainment, and higher proportions of minority populations, among other factors (1-4). Disparities in COVID-19 incidence and the impact of vaccination on incidence disparities by community income were assessed among 81 communities in Los Angeles, California. Median community vaccination coverage and COVID-19 incidence were calculated across household income strata using a generalized linear mixed effects model with Poisson distribution during three COVID-19 surge periods: two before vaccine availability (July 2020 and January 2021) and the third after vaccines became widely available in April 2021 (September 2021). Adjusted incidence rate ratios (aIRRs) during the peak month of each surge were compared across communities grouped by median household income percentile. The aIRR between communities in the lowest and highest median income deciles was 6.6 (95% CI = 2.8-15.3) in July 2020 and 4.3 (95% CI = 1.8-9.9) in January 2021. However, during the September 2021 surge that occurred after vaccines became widely availabile, model estimates did not identify an incidence disparity between the highest- and lowest-income communities (aIRR = 0.80; 95% CI = 0.35-1.86). During this surge, vaccination coverage was lowest (59.4%) in lowest-income communities and highest (71.5%) in highest-income communities (p<0.001). However, a significant interaction between income and vaccination on COVID-19 incidence (p<0.001) indicated that the largest effect of vaccination on disease incidence occured in the lowest-income communities. A 20% increase in community vaccination was estimated to have resulted in an additional 8.1% reduction in COVID-19 incidence in the lowest-income communities compared with that in the highest-income communities. These findings highlight the importance of improving access to vaccination and reducing vaccine hesitancy in underserved communities in reducing disparities in COVID-19 incidence.

The impact of life expectancy on cost-effectiveness of treatment options for clinically localized prostate cancer

BACKGROUND

Life expectancy (LE) impacts effectiveness and morbidity of prostate cancer (CaP) treatment, but its impact on cost-effectiveness is unknown. We sought to evaluate the impact of LE on the cost-effectiveness of radical prostatectomy (RP), radiation therapy (RT), and active surveillance (AS) for clinically localized disease.

METHODS

We created a Markov model to calculate incremental cost-effectiveness ratios (ICERs) for RP, RT, and AS over a 20-year time horizon from a Medicare payer perspective for low- and intermediate-risk CaP. Mortality outcomes varied by tumor risk and PCCI score, a validated proxy for LE. We performed 1,000 Monte Carlo simulations with 1-way sensitivity analyses of PCCI within each tumor risk subgroup to compare cost/quality-adjusted life years (QALYs) between treatments.

RESULTS

AS dominated RP and RT for low- and intermediate-risk disease in men with LE ≤10 years (PCCI ≥7 and ≥9, respectively). However, AS failed to dominate RP and RT for men with longer LE. For men with low-risk cancer and LE>10 years (PCCI 0-6), AS had the greatest effectiveness, but failed to dominate due to higher cost relative to RP. For men with intermediate-risk cancer with LE>10 years, AS failed to dominate due to higher cost relative to RP (PCCI 0-8) and lower effectiveness relative to RT (PCCI 0-3). The range of QALYs between RP, RT, and AS varied <13% (range: 0%-12.9%) while costs varied up to 521% (range 0.5%-521%) across PCCI scores.

CONCLUSIONS

LE strongly modulates the cost of CaP treatments. This results in AS dominating RP and RT in men with LE ≤10 years. However, in men with longer LE, AS fails to dominate primarily due to its high cumulative costs, underscoring the need for risk-adjusted AS protocols.

Prostate cancer extracellular vesicle digital scoring assay - a rapid noninvasive approach for quantification of disease-relevant mRNAs

Optimizing outcomes in prostate cancer (PCa) requires precision in characterization of disease status. This effort was directed at developing a PCa extracellular vesicle (EV) Digital Scoring Assay (DSA) for detecting metastasis and monitoring progression of PCa. PCa EV DSA is comprised of an EV purification device (i.e., EV Click Chip) and reverse-transcription droplet digital PCR that quantifies 11 PCa-relevant mRNA in purified PCa-derived EVs. A Met score was computed for each plasma sample based on the expression of the 11-gene panel using the weighted Z score method. Under optimized conditions, the EV Click Chips outperformed the ultracentrifugation or precipitation method of purifying PCa-derived EVs from artificial plasma samples. Using PCa EV DSA, the Met score distinguished metastatic (n = 20) from localized PCa (n = 20) with an area under the receiver operating characteristic curve of 0.88 (95% CI:0.78-0.98). Furthermore, longitudinal analysis of three PCa patients showed the dynamics of the Met scores reflected clinical behavior even when disease was undetectable by imaging. Overall, a sensitive PCa EV DSA was developed to identify metastatic PCa and reveal dynamic disease states noninvasively. This assay may complement current imaging tools and blood-based tests for timely detection of metastatic progression that can improve care for PCa patients.

Campaign Reform for US News and World Report Rankings

This Viewpoint discusses the perceived importance of US News and World Report hospital rankings and concerns with using specialty voting to dominate the assessment of process.

Concurrent prognostic utility of lymph node count and lymph node density for men with pathological node-positive prostate cancer

BACKGROUND

While both the number (+LN) and density (LND) of metastatic lymph nodes on radical prostatectomy lymphadenectomy predict mortality in prostate cancer, the independent impact of each on overall mortality (OM) is unknown.

METHODS

We sampled men who underwent radical prostatectomy and lymphadenectomy between 2004 and 2013 from the National Cancer Database. Multivariable Cox proportional hazards analysis with restricted cubic spline was used to assess the non-linear association of +LN count and LND with OM.

RESULTS

Of 229,547 men in our sample, 3% (n = 7507) had +LNs, of which 89% had 1-3 +LN and 11% had ≥4 +LN. In multivariable Cox analysis across all patients, OM increased with each additional +LN up to four (HR 1.14, 95%CI 1.06-1.23 per node), with no increase beyond 4 +LN. LND was an independent predictor of OM (HR 1.09, 95%CI 1.06-1.12 per 10% increase). However, after excluding patients with inadequate nodal sampling (<5 LN examined), the variation in OM explained by LND was negligible for patients with ≤3 +LN. In men with 1, 2, and 3 +LN, there was a 0.28%, 0.02%, and 0.50% increase in OM for each 10% increase in LND, compared with 1.9% and 1.6% for men with 4 or 5+ LNs.

CONCLUSIONS

While +LN count and LND independently predict OM, the impact of LND is negligible in men with ≤3 +LN, who comprise the vast majority of men with +LN. Pathological nodal staging should primarily rely on LN count rather than LND.

Expanded Parameters in Active Surveillance for Low-risk Papillary Thyroid Carcinoma: A Nonrandomized Controlled Trial

Importance

Unlike for prostate cancer, active surveillance for thyroid cancer has not achieved wide adoption. The parameters by which this approach is feasible are also not well defined, nor is the effect of patient anxiety.

Objective

To determine if expanded size/growth parameters for patients with low-risk thyroid cancer are viable, as well as to assess for cohort differences in anxiety.

Design, Setting, and Participants

This prospective nonrandomized controlled trial was conducted at a US academic medical center from 2014 to 2021, with mean [SD] 37.1 [23.3]-month follow-up. Of 257 patients with 20-mm or smaller Bethesda 5 to 6 thyroid nodules, 222 (86.3%) enrolled and selected treatment with either active surveillance or immediate surgery. Delayed surgery was recommended for size growth larger than 5 mm or more than 100% volume growth. Patients completed the 18-item Thyroid Cancer Modified Anxiety Scale over time.

Interventions

Active surveillance.

Main Outcomes and Measures

Cumulative incidence and rate of size/volume growth.

Results

Of the 222 patients enrolled, the median (IQR) age for the study population was 46.8 (36.6-58) years, and 76.1% were female. Overall, 112 patients (50.5%) underwent treatment with active surveillance. Median tumor size was 11.0 mm (IQR, 9-15), and larger tumors (10.1-20.0 mm) comprised 67 cases (59.8%). One hundred one (90.1%) continued to receive treatment with active surveillance, 46 (41.0%) had their tumors shrink, and 0 developed regional/distant metastases. Size growth of more than 5 mm was observed in 3.6% of cases, with cumulative incidence of 1.2% at 2 years and 10.8% at 5 years. Volumetric growth of more than 100% was observed in 7.1% of cases, with cumulative incidence of 2.2% at 2 years and 13.7% at 5 years. Of 110 patients who elected to undergo immediate surgery, 21 (19.1%) had equivocal-risk features discovered on final pathology. Disease severity for all such patients remained classified as stage I. Disease-specific and overall survival rates in both cohorts were 100%. On multivariable analysis, immediate surgery patients exhibited significantly higher baseline anxiety levels compared with active surveillance patients (estimated difference in anxiety scores between groups at baseline, 0.39; 95% CI, 0.22-0.55; P < .001). This difference endured over time, even after intervention (estimated difference at 4-year follow-up, 0.50; 95% CI, 0.21-0.79; P = .001).

Conclusions and Relevance

The results of this nonrandomized controlled trial suggest that a more permissive active surveillance strategy encompassing most diagnosed thyroid cancers appears viable. Equivocal-risk pathologic features exist in a subset of cases that can be safely treated, but suggest the need for more granular risk stratification. Surgery and surveillance cohorts possess oppositional levels of worry, elevating the importance of shared decision-making when patients face treatment equivalence.

Trial Registration

ClinicalTrials.gov Identifier: NCT02609685.

Variation in Communication of Competing Risks of Mortality in Prostate Cancer Treatment Consultations

PURPOSE

Men with prostate cancer prefer patient-specific, quantitative assessments of longevity in shared decision making. We sought to characterize how physicians communicate the 3 components of competing risks-life expectancy (LE), cancer prognosis and treatment-related survival benefit-in treatment consultations.

MATERIALS AND METHODS

Conversation related to LE, cancer prognosis and treatment-related survival benefit was identified in transcripts from treatment consultations of 42 men with low- and intermediate-risk disease across 10 multidisciplinary providers. Consensus of qualitative coding by multiple reviewers noted the most detailed mode of communication used to describe each throughout the consultation.

RESULTS

Physicians frequently failed to provide patient-specific, quantitative estimates of LE and cancer mortality. LE was omitted in 17% of consultations, expressed as a generalization (eg "long"/"short") in 17%, rough number of years in 31%, probability of mortality/survival at an arbitrary timepoint in 17% and in only 19% as a specific number of years. Cancer mortality was omitted in 24% of consultations, expressed as a generalization in 7%, years of expected life in 2%, probability at no/arbitrary timepoint in 40% and in only 26% as the probability at LE. Treatment-related survival benefit was often omitted; cancer mortality was reported without treatment in 38%, with treatment in 10% and in only 29% both with and without treatment. Physicians achieved "trifecta"-1) quantifying probability of cancer mortality 2) with and without treatment 3) at the patient's LE-in only 14% of consultations.

CONCLUSIONS

Physicians often fail to adequately quantify competing risks. We recommend the "trifecta" approach, reporting 1) probability of cancer mortality 2) with and without treatment 3) at the patient's LE.

Quantitative Nodal Burden and Mortality Across Solid Cancers

BACKGROUND

Nodal staging systems vary substantially across solid tumors, implying heterogeneity in the behavior of nodal variables in various contexts. We hypothesized, in contradiction to this, that metastatic lymph node (LN) number is a universal and dominant predictor of outcome across solid tumors.

METHODS

We performed a retrospective cohort analysis of 1 304 498 patients in the National Cancer Database undergoing surgery between 2004 and 2015 across 16 solid cancer sites. Multivariable Cox regression analyses were constructed using restricted cubic splines to model the association between nodal number and mortality. Recursive partitioning analysis (RPA) was used to derive nodal classification systems for each solid cancer based on metastatic LN count. The reproducibility of these findings was assessed in 1 969 727 patients from the Surveillance, Epidemiology, and End Results registry. Two-sided tests were used for all statistical analyses.

RESULTS

Consistently across disease sites, mortality risk increased continuously with increasing number of metastatic LNs (P < .001 for all spline segments). Each RPA-derived nodal classification system produced multiple prognostic groups spanning a wide spectrum of mortality risk (P < .001). Multivariable models using these RPA-derived nodal classifications demonstrated improved concordance with mortality compared with models using American Joint Committee on Cancer staging in sites where nodal classification is not based on metastatic LN count. Each RPA-derived nodal classification system was reproducible in a large validation cohort for all-cause and cause-specific mortality (P < .001). High quantitative nodal burden was the single strongest tumor-intrinsic variable associated with mortality in 12 of 16 disease sites.

CONCLUSIONS

Quantitative metastatic LN burden is a fundamental driver of mortality across solid cancers and should serve as a foundation for pathologic nodal staging across solid tumors.

Using an Automated Electronic Health Record Score To Estimate Life Expectancy In Men Diagnosed With Prostate Cancer In The Veterans Health Administration

OBJECTIVES

To determine if an automatically calculated electronic health record score can estimate intermediate-term life expectancy in men with prostate cancer to provide guideline concordant care.

METHODS

We identified all men (n = 36,591) diagnosed with prostate cancer in 2013-2015 in the VHA. Of the 36,591, 35,364 (96.6%) had an available Care Assessment Needs (CAN) score (range: 0-99) automatically calculated in the 30 days prior to the date of diagnosis. It was designed to estimate short-term risks of hospitalization and mortality. We fit unadjusted and multivariable Cox proportional hazards regression models to determine the association between the CAN score and overall survival among men with prostate cancer. We compared CAN score performance to two established comorbidity measures: The Charlson Comorbidity Index and Prostate Cancer Comorbidity Index (PCCI).

RESULTS

Among 35,364 men, the CAN score correlated with overall stage, with mean scores of 46.5 ( ± 22.4), 58.0 ( ± 24.4), and 68.1 ( ± 24.3) in localized, locally advanced, and metastatic disease, respectively. In both unadjusted and adjusted models for prostate cancer risk, the CAN score was independently associated with survival (HR = 1.23 95%CI 1.22-1.24 & adjusted HR = 1.17 95%CI 1.16-1.18 per 5-unit change, respectively). The CAN score (overall C-Index 0.74) yielded better discrimination (AUC = 0.76) than PCCI (AUC = 0.65) or Charlson Comorbidity Index (AUC = 0.66) for 5-year survival.

CONCLUSION

The CAN score is strongly associated with intermediate-term survival following a prostate cancer diagnosis. The CAN score is an example of how learning health care systems can implement multi-dimensional tools to provide fully automated life expectancy estimates to facilitate patient-centered cancer care.

Time Trends in Use of Radical Prostatectomy by Tumor Risk and Life Expectancy in a National Veterans Affairs Cohort

IMPORTANCE

Guidelines endorse using tumor risk and life expectancy (LE) to select appropriate candidates for radical prostatectomy (RP), recommending against treatment of most low-risk tumors and men with limited LE.

OBJECTIVE

To investigate time trends in the use of RP by tumor risk and Prostate Cancer Comorbidity Index (PCCI) score in a contemporary, nationally representative Veterans Affairs (VA) cohort.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of 5736 men treated with RP at 8 VA hospitals from January 1, 2000, to December 31, 2017, used a nationally representative, multicenter sample from the VA SEARCH (Shared Equal Access Regional Cancer Hospital) database. Statistical analysis was performed from June 30, 2018, to August 20, 2020.

MAIN OUTCOMES AND MEASURES

Stratified linear and log-linear Poisson regressions were used to estimate time trends in the proportion of men treated with RP across American Urological Association tumor risk and PCCI (a validated predictor of LE based on age and comorbidities) subgroups.

RESULTS

Among 5736 men (mean [SD] age at surgery, 62 [6] years) treated with RP from 2000 to 2017, the proportion of low-risk tumors treated with RP decreased from 51% to 7% (difference, -44%; 95% CI, -50% to -38%). The proportion of intermediate-risk tumors treated with RP increased from 30% to 59% (difference, 29%; 95% CI, 23%-35%), with unfavorable intermediate-risk tumors increasing from 30% to 41% (difference, 11%; 95% CI, 4%-18%) and favorable intermediate-risk tumors decreasing from 61% to 41% (difference, -20%; 95% CI, -24% to -15%). The proportion of high-risk tumors treated with RP increased from 18% to 33% (difference, 15%; 95% CI, 9%-21%). Among men treated with RP, the proportion with the highest PCCI scores of 10 or more (ie, LE <10 years) increased from 4% to 13% (difference, 9%; 95% CI, 4%-14%). Within each tumor risk subgroup, no significant difference in the rate of tumors treated with RP over time was found across PCCI subgroups.

CONCLUSIONS AND RELEVANCE

In this study, the use of RP shifted from low-risk and favorable intermediate-risk to higher-risk prostate cancer. However, its use among men with limited LE appears unchanged across tumor risk subgroups and increased overall.

The Impact of Comorbidity and Age on Timing of Androgen Deprivation Therapy in Men with Biochemical Recurrence after Radical Prostatectomy

INTRODUCTION

Older men with major comorbidities have higher risks of morbidity and mortality from androgen deprivation therapy, and the benefits of immediate androgen deprivation therapy after biochemical recurrence in these men are unclear. We assessed variation in timing of androgen deprivation therapy by age and comorbidity in a cohort of men with biochemical recurrence after radical prostatectomy.

METHODS

We analyzed 2,097 men with biochemical recurrence after radical prostatectomy from 2000 to 2017 in the VA SEARCH database. We ascertained age and Deyo-Charlson comorbidity index scores at biochemical recurrence. Kaplan-Meier analysis and multivariable logistic regression were used to determine association of age and Deyo-Charlson comorbidity index with prostate specific antigen at the initiation of androgen deprivation therapy.

RESULTS

In Kaplan-Meier analysis with prostate specific antigen at androgen deprivation therapy as the outcome, median prostate specific antigen at androgen deprivation therapy initiation was 6.2 ng/ml (95% CI 5.1-7.1) across all patients but differed among those who received adjuvant/salvage radiation (3.6 ng/ml, 95% CI 2.8-4.3) and those who did not (12.1 ng/ml, 95% CI 9.6-15.2, p <0.001). In multivariable Cox regression, advanced age (p=0.03) but not worse comorbidity (p=0.25) was associated higher prostate specific antigen at initiation of androgen deprivation therapy. Across all patients, prostate specific antigen at androgen deprivation therapy was lower among those <60 years old (3.7 ng/ml, 95% CI 2.6-5.8) compared to those 60-64 (5.0 ng/ml, 95% CI 3.9-6.6), 65-69 (6.6 ng/ml, 95% CI 4.9-8.8), 70-74 (8.8 ng/ml, 95% CI 6.1-12.3) and ≥75 years old (14.1 ng/ml, 95% CI 5.5-37.8). In contrast, prostate specific antigen at androgen deprivation therapy was similar among comorbidity subgroups (Deyo-Charlson comorbidity index 0: 6.3 ng/ml, 95% CI 5.0-7.9 vs Deyo-Charlson comorbidity index 3 or higher: 5.6 ng/ml, 95% CI 4.1-7.4). In general, these relationships were consistent among subgroups receiving adjuvant/salvage radiation.

CONCLUSIONS

Men with comorbid disease at increased risk of morbidity and mortality with androgen deprivation therapy often receive androgen deprivation therapy at low prostate specific antigen values.

Effect of Androgen Deprivation on Long-term Outcomes of Intermediate-Risk Prostate Cancer Stratified as Favorable or Unfavorable: A Secondary Analysis of the RTOG 9408 Randomized Clinical Trial

This secondary analysis of a randomized clinical trial examines the effect of androgen deprivation therapy (ADT) during radiotherapy in patients who were classified as having either favorable intermediate-risk or unfavorable intermediate-risk prostate cancer.

Life expectancy estimates for patients diagnosed with prostate cancer in the Veterans Health Administration

PURPOSE

Accurate life expectancy estimates are required to inform prostate cancer treatment decisions. However, few models are specific to the population served or easily implemented in a clinical setting. We sought to create life expectancy estimates specific to Veterans diagnosed with prostate cancer.

MATERIALS AND METHODS

Using national Veterans Health Administration electronic health records, we identified Veterans diagnosed with prostate cancer between 2000 and 2015. We abstracted demographics, comorbidities, oncologic staging, and treatment information. We fit Cox Proportional Hazards models to determine the impact of age, comorbidity, cancer risk, and race on survival. We stratified life expectancy estimates by age, comorbidity and cancer stage.

RESULTS

Our analytic cohort included 145,678 patients. Survival modeling demonstrated the importance of age and comorbidity across all cancer risk categories. Life expectancy estimates generated from age and comorbidity data were predictive of overall survival (C-index 0.676, 95% CI 0.674-0.679) and visualized using Kaplan-Meier plots and heatmaps stratified by age and comorbidity. Separate life expectancy estimates were generated for patients with localized or advanced disease. These life expectancy estimates calibrate well across prostate cancer risk categories.

CONCLUSIONS

Life expectancy estimates are essential to providing patient-centered prostate cancer care. We developed accessible life expectancy estimation tools for Veterans diagnosed with prostate cancer that can be used in routine clinical practice to inform medical-decision making.

The Personalized Medicine for Prostate Cancer (PMPC) Study: The role of race, genomics, and patient complexity in treatment outcomes

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Background: Matching of patients with optimal treatment for localized prostate cancer (PCa) requires accurate estimates of risk for progression or recurrence. Traditional risk assessment methods may underestimate risk for certain patient subgroups, (e.g. minorities). In the PMPC study, we replicated an expanded risk model, adding genomic data to improve risk prediction and optimize treatment assignment for PCa. Methods: A prospective cohort of 660 patients with early PCa was identified from 3 teaching hospitals and 2 VA Hospitals in Southern California. Risk model data were collected from electronic medical records, patient questionnaires and tissue-based genomic data provided by GenomeDx. Complexity variables included demographic characteristics, clinical markers (PSA levels, Gleason score), patient-reported health status measures (e.g. comorbidity burden, depression, stress) and Decipher score. We compared individual components of the complexity score for 425 Non-Hispanic White (NHW) and 104 African American (AA) men using t-tests. Composite complexity scores were derived from weights from general linear models. Mean complexity scores were compared using t-tests. Results: Compared with NHW men, AA men had statistically significantly more comorbidity, poorer health ratings, poorer physical functioning, more depression, less energy, more fatigue, more stress and less resilience. More AA men had Gleason scores >6 (60.0%) than NHW men (46.6%), p=.0134. Fewer AA men (41.5%) had ‘low risk’ Decipher scores compared to NHW men (53.8%). More AA men had high complexity scores compared with NHW men (63.4% vs. 45.1%, p=.008), however, there were no statistically significant differences in the proportion of NHW vs. AA men on active surveillance, 46.0% vs. 40.7%, p=.384. Using clinical variables alone there were no significant differences in low risk between NHW and AA men. Conclusions: The addition of genomic data improved the complexity model developed earlier. AA men may be at higher risk for suboptimal treatment than predicted by clinical variables alone. Data from the longitudinal cohort will test accuracy of model prediction for disease progression or recurrence. Clinical trial information: NCT03770351.

Parallels Between Low-Risk Prostate Cancer and Thyroid Cancer: A Review

Importance

Across many countries, a rapid escalation of the incidence of thyroid cancer has been observed, a surge that nonetheless underestimates the true extent of the disease. Most thyroid cancers now diagnosed comprise small, low-risk cancers that are incidentally found and are unlikely to cause harm. In many ways, prostate cancer similarly harbors a well-behaved subclinical reservoir, a long natural history, and superlative outcomes that have made active surveillance the de facto guideline recommendation for low-risk disease. This review highlights the parallels and differences between prostate cancer and thyroid cancer regarding screening, diagnosis, risk stratification, and considerations for active surveillance.

Observations

Prostate cancer and thyroid cancer have undergone recalibrated, de-escalatory shifts to counter changing epidemiologic landscapes. The US Preventive Services Task Force has issued cautionary recommendations on screening via prostate-specific antigen testing or neck ultrasonography, while the thresholds to performing biopsy have increased. Comparable changes to cancer terminology and staging have also helped alleviate patient anxiety and minimize pressure for overtreatment. Long-term, randomized prospective clinical trials for prostate cancer have established active surveillance as a first-line treatment approach for properly stratified low-risk patients, while observational trials for thyroid cancer have also made strides in defining risk and eligibility for surgery. Caveats requiring deeper investigation include aggressive disease in older patients, underestimation of the extent of the disease, and patient-physician bias in shared decision making. For prostate cancer, survival may not improve and function will likely worsen after intervention; for thyroid cancer, patients are younger, surgery is safer, and the bar for surveillance will likely be higher.

Conclusions and Relevance

Despite similarities in biological indolence between low-risk prostate and thyroid malignant neoplasms, key distinctions in life expectancy and treatment sequelae may ultimately confer somewhat disparate management paradigms for the 2 diseases. Nevertheless, the experience forged by prostate cancer trials serves as a model for thyroid cancer management, potentially reshaping the perception of active surveillance into a credible, valuable treatment modality.

Association of Social Media Presence with Online Physician Ratings and Surgical Volume Among California Urologists: Observational Study

BACKGROUND

Urologists are increasingly using various forms of social media to promote their professional practice and attract patients. Currently, the association of social media on a urologists' practice is unknown.

OBJECTIVES

We aimed to determine whether social media presence is associated with higher online physician ratings and surgical volume among California urologists.

METHODS

We sampled 195 California urologists who were rated on the ProPublica Surgeon Scorecard website. We obtained information on professional use of online social media (Facebook, Instagram, Twitter, blog, and YouTube) in 2014 and defined social media presence as a binary variable (yes/no) for use of an individual platform or any platform. We collected data on online physician ratings across websites (Yelp, Healthgrades, Vitals, RateMD, and UCompareHealthcare) and calculated the mean physician ratings across all websites as an average weighted by the number of reviews. We then collected data on surgical volume for radical prostatectomy from the ProPublica Surgeon Scorecard website. We used multivariable linear regression to determine the association of social media presence with physician ratings and surgical volume.

RESULTS

Among our sample of 195 urologists, 62 (32%) were active on some form of social media. Social media presence on any platform was associated with a slightly higher mean physician rating (β coefficient: .3; 95% CI 0.03-0.5; P=.05). However, only YouTube was associated with higher physician ratings (β coefficient: .3; 95% CI 0.2-0.5; P=.04). Social media presence on YouTube was strongly associated with increased radical prostatectomy volume (β coefficient: 7.4; 95% CI 0.3-14.5; P=.04). Social media presence on any platform was associated with increased radical prostatectomy volume (β coefficient: 7.1; 95% CI -0.7 to 14.2; P=.05).

CONCLUSIONS

Urologists' use of social media, especially YouTube, is associated with a modest increase in physician ratings and prostatectomy volume. Although a majority of urologists are not currently active on social media, patients may be more inclined to endorse and choose subspecialist urologists who post videos of their surgical technique.

Online physician ratings fail to predict actual performance on measures of quality, value, and peer review

Objective

Patients use online consumer ratings to identify high-performing physicians, but it is unclear if ratings are valid measures of clinical performance. We sought to determine whether online ratings of specialist physicians from 5 platforms predict quality of care, value of care, and peer-assessed physician performance.

Materials and Methods

We conducted an observational study of 78 physicians representing 8 medical and surgical specialties. We assessed the association of consumer ratings with specialty-specific performance scores (metrics including adherence to Choosing Wisely measures, 30-day readmissions, length of stay, and adjusted cost of care), primary care physician peer-review scores, and administrator peer-review scores.

Results

Across ratings platforms, multivariable models showed no significant association between mean consumer ratings and specialty-specific performance scores (β-coefficient range, -0.04, 0.04), primary care physician scores (β-coefficient range, -0.01, 0.3), and administrator scores (β-coefficient range, -0.2, 0.1). There was no association between ratings and score subdomains addressing quality or value-based care. Among physicians in the lowest quartile of specialty-specific performance scores, only 5%-32% had consumer ratings in the lowest quartile across platforms. Ratings were consistent across platforms; a physician's score on one platform significantly predicted his/her score on another in 5 of 10 comparisons.

Discussion

Online ratings of specialist physicians do not predict objective measures of quality of care or peer assessment of clinical performance. Scores are consistent across platforms, suggesting that they jointly measure a latent construct that is unrelated to performance.

Conclusion

Online consumer ratings should not be used in isolation to select physicians, given their poor association with clinical performance.

Association of Wearable Activity Monitors With Assessment of Daily Ambulation and Length of Stay Among Patients Undergoing Major Surgery

IMPORTANCE

Early postoperative ambulation is vital to minimizing length of stay (LOS), but few hospitals objectively measure ambulation to predict outcomes. Wearable activity monitors have the potential to transform assessment of postoperative ambulation, but key implementation data, including whether digitally monitored step count can identify patients at risk for poor efficiency outcomes, are lacking.

OBJECTIVES

To define the distribution of digitally measured daily step counts after major inpatient surgical procedures, to assess the accuracy of physician assessment and ordering of ambulation, and to quantify the association of digitally measured step count with LOS.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study at Cedars-Sinai Medical Center, an urban tertiary referral center. Participants were patients undergoing 8 inpatient operations (lung lobectomy, gastric bypass, hip replacement, robotic cystectomy, open colectomy, abdominal hysterectomy, sleeve gastrectomy, and laparoscopic colectomy) from July 11, 2016, to August 30, 2017.

INTERVENTIONS

Use of activity monitors to measure daily postoperative step count.

MAIN OUTCOMES AND MEASURES

Operation-specific daily step count, daily step count by physician orders and assessment, and a prolonged LOS (>70th percentile for each operation).

RESULTS

Among 100 patients (53% female), the mean (SD) age was 53 (18) years, and the median LOS was 4 days (interquartile range, 3-6 days). There was a statistically significant increase in daily step count with successive postoperative days in aggregate (r = 0.55; 95% bootstrapped CI, 0.47-0.62; P < .001) and across individual operations. Ninety-five percent (356 of 373) of daily ambulation orders were "ambulate with assistance," although daily step counts ranged from 0 to 7698 steps (0-5.5 km) under this order. Physician estimation of ambulation was predictive of the median step count (r = 0.66; 95% bootstrapped CI, 0.59-0.72; P < .001), although there was substantial variation within each assessment category. For example, daily step counts ranged from 0 to 1803 steps (0-1.3 km) in the "out of bed to chair" category. Higher step count on postoperative day 1 was associated with lower odds of prolonged LOS from 0 to 1000 steps (odds ratio [OR], 0.63; 95% CI, 0.45-0.84; P = .003), with no further decrease in odds after 1000 steps (OR, 0.99; 95% CI, 0.75-1.30; P = .80).

CONCLUSIONS AND RELEVANCE

In this study, digitally measured step count up to 1000 steps on postoperative day 1 was associated with lower probability of a prolonged LOS. Wearable activity monitors improved the accuracy of assessment of daily step count over the current standard of care, providing an opportunity to identify patients at risk for poor efficiency outcomes.

Impact of age, comorbidity, and PSA doubling time on long-term competing risks for mortality among men with non-metastatic castration-resistant prostate cancer

BACKGROUND

Understanding competing risks for mortality is critical in determining prognosis among men with non-metastatic castration-resistant prostate cancer (nmCRPC), a disease state that often affects older men and has substantial heterogeneity in risk of cancer mortality. We sought to determine the impact of age, comorbidity, and PSA doubling time (PSADT) on competing risks for mortality in men with nmCRPC.

METHODS

We conducted a retrospective analysis of 1238 patients diagnosed with nmCRPC in 2000-2015 in the SEARCH database. Multivariable Cox proportional hazards and competing risks regression were used to determine the hazards of overall, prostate cancer-specific (PCSM), and other-cause mortality (OCM) across age, Charlson comorbidity index (CCI), and PSADT subgroups.

RESULTS

Men with nmCRPC were elderly (median age 77) and had substantial comorbidity burdens (CCI > 1 n = 701, 57%). Multivariable Cox analysis showed higher CCI was associated with higher hazard of OCM, while slower PSADT was associated with lower hazard of PCSM across all age subgroups. Among those with CCI ≥ 3 (vs. CCI0), the hazard ratio of OCM was 2.7 (95% CI 1.1-6.3), 2.0 (95% CI 1.1-3.6), and 2.5 (95% CI 1.5-4.0) for those aged <70, 70-79, and ≥80, respectively. Among those with PSADT ≥ 9 months (vs. < 9 months), the hazard ratios for PCSM were 0.5 (95% CI 0.3-0.9), 0.6 (95% CI 0.4-0.9), and 0.6 (95% CI 0.4-0.9) for those aged <70, 70-79, and ≥80. Competing risks curves revealed PCSM was the predominant cause of death for those with PSADT < 9 months across all age and comorbidity groups. PCSM and OCM were relatively equal competitors for mortality among those with PSADT≥9 months except those aged > 80 with CCI ≥ 3, in whom OCM was the predominant cause of death.

CONCLUSIONS

Among men with nmCRPC, age, comorbidity, and PSADT are associated with risk and cause of death and may assist clinicians in counseling patients regarding cancer prognosis.

Development of a Nationally Representative Coordinated Registry Network for Prostate Ablation Technologies

PURPOSE

The accumulation of data through a prospective, multicenter coordinated registry network is a practical way to gather real world evidence on the performance of novel prostate ablation technologies. Urological oncologists, targeted biopsy experts, industry representatives and representatives of the FDA (Food and Drug Administration) convened to discuss the role, feasibility and important data elements of a coordinated registry network to assess new and existing prostate ablation technologies.

MATERIALS AND METHODS

A multiround Delphi consensus approach was performed which included the opinion of 15 expert urologists, representatives of the FDA and leadership from high intensity focused ultrasound device manufacturers. Stakeholders provided input in 3 consecutive rounds with conference calls following each round to obtain consensus on remaining items. Participants agreed that these elements initially developed for high intensity focused ultrasound are compatible with other prostate ablation technologies. Coordinated registry network elements were reviewed and supplemented with data elements from the FDA common study metrics.

RESULTS

The working group reached consensus on capturing specific patient demographics, treatment details, oncologic outcomes, functional outcomes and complications. Validated health related quality of life questionnaires were selected to capture patient reported outcomes, including the IIEF-5 (International Index of Erectile Function-5), the I-PSS (International Prostate Symptom Score), the EPIC-26 (Expanded Prostate Cancer Index Composite-26) and the MSHQ-EjD (Male Sexual Health Questionnaire for Ejaculatory Dysfunction). Group consensus was to obtain followup multiparametric magnetic resonance imaging and prostate biopsy approximately 12 months after ablation with additional imaging or biopsy performed as clinically indicated.

CONCLUSIONS

A national prostate ablation coordinated registry network brings forth vital practice pattern and outcomes data for this emerging treatment paradigm in the United States. Our multiple stakeholder consensus identifies critical elements to evaluate new and existing energy modalities and devices.

Electronic health record problem lists: accurate enough for risk adjustment?

OBJECTIVES

To determine whether comorbidity information derived from electronic health record (EHR) problem lists is accurate.

STUDY DESIGN

Retrospective cohort study of 1596 men diagnosed with prostate cancer between 1998 and 2004 at 2 Southern California Veterans Affairs Medical Centers with long-term follow-up.

METHODS

We compared EHR problem list-based comorbidity assessment with manual review of EHR free-text notes in terms of sensitivity and specificity for identification of major comorbidities and Charlson Comorbidity Index (CCI) scores. We then compared EHR-based CCI scores with free-text-based CCI scores in prediction of long-term mortality.

RESULTS

EHR problem list-based comorbidity assessment had poor sensitivity for detecting major comorbidities: myocardial infarction (8%), cerebrovascular disease (32%), diabetes (46%), chronic obstructive pulmonary disease (42%), peripheral vascular disease (31%), liver disease (1%), and congestive heart failure (23%). Specificity was above 94% for all comorbidities. Free-text-based CCI scores were predictive of long-term other-cause mortality, whereas EHR problem list-based scores were not.

CONCLUSIONS

Inaccuracies in EHR problem list-based comorbidity data can lead to incorrect determinations of case mix. Such data should be validated prior to application to risk adjustment.

Salvage Radiotherapy for Biochemically Recurrent Prostate Cancer After Prostatectomy

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 67-year-old man had presented to his primary physician for routine health maintenance. A digital rectal examination was performed and revealed a suspicious nodule in the right lobe of the prostate without any extraprostatic extension. A serum prostate-specific antigen (PSA) test was 12.4 ng/mL. He had no previous PSA tests. Transrectal ultrasound-guided prostate biopsy showed Gleason 3 + 4 prostate adenocarcinoma in seven of 12 cores. Bone scan and computed tomography scan of the pelvis showed no evidence of metastatic disease, and the patient underwent a robotic-assisted radical prostatectomy with bilateral pelvic lymphadenectomy. Pathology revealed Gleason 3 + 4 adenocarcinoma bilaterally, with extracapsular extension, no seminal vesicle invasion, a 2-mm positive margin at the right mid gland, and 0 of 15 lymph nodes containing adenocarcinoma. Two months after surgery, he had mild stress urinary incontinence and PSA of < 0.1 ng/mL. Adjuvant radiotherapy was discussed, but he elected to have careful follow-up. His PSA was monitored every 6 months and gradually increased from < 0.1 ng/mL to 0.4 ng/mL over the next 3 years. He was asymptomatic. He was referred to discuss the role of salvage radiotherapy.

Online Ratings Systems for Physicians and Institutions: Limitations of the Current State of the Art

Consumers are increasingly using online ratings tools that compare surgeons and institutions to identify high-quality providers. However, concerns regarding their limitations-data quality, validity of statistical comparisons, and impact on access to care-should be considered before full-scale implementation.

Patient function, long-term survival, and use of surgery in patients with kidney cancer

BACKGROUND

Beyond age and comorbidity, functionality can shape the long-term survival potential of patients with cancer. Accordingly, herein the authors compared mortality and receipt of cancer-directed surgery according to patient function among older adults with kidney cancer.

METHODS

Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 2000 through 2009, the authors studied 28,326 elderly subjects with primary kidney cancer. Patient function was quantified using function-related indicators, claims indicative of dysfunction and disability. Adjusting for patient and cancer characteristics, competing risk regression was used to assess the relationship between function-related indicator count and cause-specific mortality and then generalized estimating equations were used to quantify the probability of surgery.

RESULTS

A total of 13,619 adult patients (48.1%) with at least 1 function-related indicator were identified. A higher indicator category was associated with older age, greater comorbidity, female sex, unmarried status, lower socioeconomic status, and higher stage of disease (P<.001). Compared with patients with an indicator count of 0, those with an indicator count of 1 (hazard ratio, 1.10; 95% confidence interval [95% CI], 1.04-1.16) and ≥2 (hazard ratio, 1.46; 95% CI, 1.39-1.53) were found to have higher other-cause mortality. Conversely, kidney cancer mortality varied minimally with patient function. Patients with ≥ 2 indicators received cancer-directed surgery less often than those without disability (odds ratio, 0.61; 95% CI, 0.56-0.66), although treatment probabilities remained high for patients with locoregional disease and low for those with metastatic cancer.

CONCLUSIONS

Among older adults with kidney cancer, functional health stands as a significant predictor of long-term survival. However, receipt of cancer-directed surgery appears largely determined by cancer stage. Patient function should be considered more heavily when determining treatment for older adults with kidney cancer. Cancer 2016;122:3776-3784. © 2016 American Cancer Society.

Use, complications, and costs of stereotactic body radiotherapy for localized prostate cancer

BACKGROUND

Stereotactic body radiotherapy (SBRT) for localized prostate cancer has potential advantages over traditional radiotherapies. Herein, the authors compared national trends in use, complications, and costs of SBRT with those of traditional radiotherapies.

METHODS

The authors identified men who underwent SBRT, intensity-modulated radiotherapy (IMRT), brachytherapy, and proton beam therapy as primary treatment of prostate cancer between 2004 and 2011 from Surveillance, Epidemiology, and End Results Program (SEER)-Medicare linked data. Temporal trend of therapy use was assessed using the Cochran-Armitage test. Two-year outcomes were compared using the chi-square test. Median treatment costs were compared using the Kruskal-Wallis test.

RESULTS

A total of 542 men received SBRT, 9647 received brachytherapy, 23,408 received IMRT, and 800 men were treated with proton beam therapy. There was a significant increase in the use of SBRT and proton beam therapy (P<.001), whereas brachytherapy use decreased (P<.001). A higher percentage of patients treated with SBRT and brachytherapy had low-grade cancer (Gleason score ≤ 6 vs ≥ 7) compared with individuals treated with IMRT and proton beam therapy (54.0% and 64.2% vs 35.2% and 49.6%, respectively; P<.001). SBRT compared with brachytherapy and IMRT was associated with equivalent gastrointestinal toxicity but more erectile dysfunction at 2-year follow-up (P<.001). SBRT was associated with more urinary incontinence compared with IMRT and proton beam therapy but less compared with brachytherapy (P<.001, respectively). The median cost of SBRT was $27,145 compared with $17,183 for brachytherapy, $37,090 for IMRT, and $54,706 for proton beam therapy (P<.001).

CONCLUSIONS

The use of SBRT and proton beam therapy for localized prostate cancer has increased over time. Despite men of lower disease stage undergoing SBRT, SBRT was found to be associated with greater toxicity but lower health care costs compared with IMRT and proton beam therapy. Cancer 2016;122:2496-504. © 2016 American Cancer Society.

Life Expectancy and Variation in Treatment for Early Stage Kidney Cancer

PURPOSE

Patients with limited life expectancy are at risk for overtreatment of T1a kidney cancer. We sought to determine patterns of treatment for T1a kidney cancer in a nationally representative sample of patients with life expectancy less than 10 and less than 5 years.

MATERIALS AND METHODS

We sampled 9,825 patients older than 65 years with clinical T1a kidney cancer diagnosed between 2000 and 2010 from the SEER (Surveillance, Epidemiology and End Results)-Medicare database. We performed competing risks regression to model survival by age/comorbidity and identified patients with life expectancy less than 10 and less than 5 years. Multivariate logistic regression was used to determine the probability of aggressive treatment with surgery or ablation among those with limited life expectancy.

RESULTS

Life expectancy was less than 10 years in patients 66 to 80 years old with a Charlson score of 3+, in those 80 to 84 years old with a Charlson score of 1+ and in all patients 85 years old or older. Among those with life expectancy less than 10 years the multivariate probability of aggressive treatment was 85%, 84%, 82%, 75% and 50% in those 66 to 69, 70 to 74, 75 to 79, 80 to 84 and 85 years old or older, respectively. In those with life expectancy less than 10 years who were treated aggressively treatment was radical nephrectomy in 61%, partial nephrectomy in 24% and ablation in 14%. Among those with life expectancy less than 5 years (age 85 years or greater with a Charlson score of 3+) the multivariate probability of aggressive treatment was 41% and more often surgery than ablation (68% vs 32% of patients).

CONCLUSIONS

The majority of patients with life expectancy less than 10 years and a significant minority with life expectancy less than 5 years were treated with surgery or ablation for T1a kidney cancer. Life expectancy should be better incorporated into treatment decision making for early stage kidney cancer.

Progressive Independence in Clinical Training: Perspectives of a National, Multispecialty Panel of Residents and Fellows

BACKGROUND

Progressive independence in patient care activities is imperative for residents' readiness for practice and patient safety of those cared for by graduates of residency programs. However, establishing a standardized system of progressive independence is an ongoing challenge in graduate medical education.

OBJECTIVE

We aggregated trainees' perspectives on progressive independence, developed a model of the ideal state, and suggested actionable improvements.

METHODS

A multispecialty, nationally representative group of trainees conducted a structured exercise that (1) described the attributes of an ideal system of graduated responsibility; (2) compared the current system to that ideal; (3) developed benchmarks to reinforce best practices; and (4) identified approaches to motivate programs to adopt best practices.

RESULTS

At the core of an ideal model of graduated responsibility is a well-structured curriculum and assessment of individual learners using educational milestones and patient outcomes. The ideal model also includes robust faculty development and emphasizes faculty mentorship. To address legal and financial restrictions that pose barriers to progressive independent, objective outcome criteria like the milestones could be used to ask payers to alter payment restrictions for work performed by senior trainees, providing financial incentives for programs to encourage appropriate independent practice. Recognition of high-performing programs at the national level could motivate others to adopt best practices.

CONCLUSIONS

A multifaceted approach, incorporating robust 2-way feedback about skill level and autonomy between residents and faculty, along with improved faculty development in this area, is needed to optimize residents' attainment of progressive independence. There are incentives to move programs and institutions toward this optimal model.

Improving Health Care for the Future Uninsured in Los Angeles County: A Community-Partnered Dialogue

OBJECTIVE

To understand the health care access issues faced by Los Angeles (LA) County's uninsured and residually uninsured after implementation of the Affordable Care Act (ACA) and to identify potential solutions using a community-partnered dialogue.

DESIGN

Qualitative study using a community-partnered participatory research framework.

SETTING

Community forum breakout discussion.

DISCUSSANTS

Representatives from LA County health care agencies, community health care provider organizations, local community advocacy and service organizations including uninsured individuals, and the county school district.

MAIN OUTCOME MEASURES

Key structural and overarching value themes identified through community-partnered pile sort, c-coefficients measuring overlap between themes.

RESULTS

Five overarching value themes were identified - knowledge, trust, quality, partnership, and solutions. Lack of knowledge and misinformation were identified as barriers to successful enrollment of the eligible uninsured and providing health care to undocumented individuals. Discussants noted dissatisfaction with the quality of traditional sources of health care and a broken cycle of trust and disengagement. They also described inherent trust by the uninsured in "outsider" community-based providers not related to quality.

CONCLUSIONS

Improving health care for the residually uninsured after ACA implementation will require addressing dissatisfaction in safety-net providers, disseminating knowledge and providing health care through trusted nontraditional sources, and using effective and trusted partnerships between community and health care agencies with mutual respect. Community-academic partnerships can be a trusted conduit to discuss issues related to the health care of vulnerable populations.