Prevalence of Adolescents Meeting Criteria for Metabolic and Bariatric Surgery

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics endorses metabolic and bariatric surgery (MBS) as a safe and effective treatment of severe obesity in children with class 3 obesity or with class 2 obesity and qualifying comorbidities. The study objective was to determine eligibility and characteristics of adolescents who qualify for MBS based on American Academy of Pediatrics guidelines.

METHODS

This retrospective cohort study analyzed electronic health record data of 603 051 adolescents aged 13 to 17 years between January 1, 2018, and December 31, 2021. Centers for Disease Control and Prevention criteria were used to define obesity classes 2 and 3. Multivariable logistic regression was used to evaluate the factors associated with meeting MBS eligibility criteria.

RESULTS

Of the 603 041 adolescents evaluated, 22.2% had obesity (12.9% class 1, 5.4% class 2, and 3.9% class 3). The most frequently diagnosed comorbid conditions were gastroesophageal reflux disease (3.2%), hypertension (0.5%), and nonalcoholic fatty liver disease (0.5%). Among adolescents with class 2 obesity, 9.1% had 1 or more comorbidities qualifying for MBS, and 4.4% of all adolescents met the eligibility criteria for MBS. In multivariable modeling, males, Black and Hispanic adolescents, and those living in more deprived neighborhoods were more likely to meet MBS eligibility criteria.

CONCLUSIONS

Overall, 1 in 23 adolescents met the eligibility criteria for MBS. Demographic and social determinants were associated with a higher risk for meeting these criteria. The study suggests that the health care system may face challenges in accommodating the demand for MBS among eligible adolescents.

Ten-Year Trends in Preventive Service Use Before and After Prostate Cancer Diagnosis: A Comparison with Noncancer Controls

CONTEXT

Few studies have assessed the longer-term quality of preventive care in prostate cancer (PCa) survivors.

OBJECTIVE

To compare the rates of preventive services among PCa survivors five years before and after diagnosis, to men without PCa.

DESIGN

Men enrolled in Kaiser Permanente Southern California with newly diagnosed PCa (2002-2008) were matched 1:1 to men without a PCa diagnosis on age, race, and timing of prostate-specific antigen test (N = 31,180). The use of preventive services, including colorectal cancer screening, diabetes tests, lipid panels, and influenza and pneumococcal vaccinations was assessed 5 years before and after diagnosis (or index date for controls).

MAIN OUTCOME MEASURES

Relative rates (RRs) of use were calculated for cases and controls separately and compared using Poisson regression, adjusting for comorbidities and outpatient utilization in 2014.

RESULTS

Overall, the rates of preventive services were lower among men with PCa vs men without PCa. However, in the 5 years after diagnosis, rates of preventive service use for all services were greater among PCa survivors vs men without PCa (colorectal cancer: RR = 1.05, 95% confidence interval [CI] = 1.01-1.10; lipids: RR = 1.10, 95% CI = 1.08-1.11; hemoglobin A_1C: RR = 1.17, 95% CI = 1.14-1.19; glucose: RR = 1.24, 95% CI = 1.23-1.26; influenza vaccine: RR = 1.05, 95% CI = 1.03-1.07; pneumococcal vaccine: RR = 1.03, 95% CI = 0.97-1.09).

CONCLUSION

Delivery of preventive care improved after PCa diagnosis, with survivors receiving comparable preventive care to men without PCa during the five years following diagnosis.

The Relationship Between Nonsteroidal Anti-inflammatory Drug Use and Age-related Macular Degeneration

PURPOSE

To describe the relationship between the incidence of age-related macular degeneration (AMD) and nonsteroidal anti-inflammatory drug (NSAIDs) use.

DESIGN

Prospective cohort study.

METHODS

This study consisted of participants in the California Men's Health Study. Those who completed surveys in 2002-2003 and 2006 were included. Men who self-reported use of aspirin, ibuprofen, naproxen, valdecoxib, celecoxib, and/or rofecoxib at least 3 days per week were considered NSAID users. Patients were categorized as non-users, former users, new users, or longer-term users based on survey responses. NSAID use was also categorized by type: any NSAIDs, aspirin, and/or non-aspirin NSAIDs. Age, race/ethnicity, smoking status, education, income, alcohol use, and Charlson comorbidity index score were included in the multivariate analysis as risk factors for AMD.

RESULTS

A total of 51 371 men were included. Average follow-up time was 7.4 years. There were 292 (0.6%) and 1536 (3%) cases of exudative and nonexudative AMD, respectively. Longer-term use of any NSAID was associated with lower risk of exudative AMD (hazard ratio [HR] 0.69, 95% confidence interval [CI] 0.50-0.96, P = .029). New users of any NSAIDs (HR = 0.79, 95% CI 0.68-0.93, P = .0039) and aspirin (HR = 0.82, 95% CI 0.70-0.97, P = .018) had a lower risk of nonexudative AMD, although this trend did not persist in longer-term users. The relationship between exudative or nonexudative AMD and the remaining categories of NSAID use were not significant.

CONCLUSION

The overall impact of NSAIDs on AMD incidence is small; however, the lower risk of exudative AMD in longer-term NSAID users may point to a protective effect and deserves further study as a possible mechanism to modulate disease risk.

Racial and Ethnic Variation in Health-Related Quality of Life Scores Prior to Prostate Cancer Treatment

Introduction

Many men diagnosed with prostate cancer are concerned with how the disease and its course of treatment could affect their health-related quality of life (HRQOL). To aid in the decision-making process on a course of treatment and to better understand how these treatments can affect HRQOL, knowledge of pretreatment HRQOL is essential.

Aims

To assess the racial and ethnic variations in HRQOL scores in men newly diagnosed with prostate cancer before electing a course of treatment.

Methods

Male members of the Kaiser Permanente of Southern California health plan who were newly diagnosed with prostate cancer completed the five-domain specific Expanded Prostate Index Composite–26 (EPIC-26) HRQOL questionnaire from March 1, 2011 through August 31, 2013 (N = 2,579). Domain scores were compared across racial and ethnic subgroups and multiple logistic regression analyses were used to assess the association after adjusting for sociodemographic and clinical characteristics.

Main Outcome Measures

The five EPIC-26 domain scores (sexual, bowel, hormonal, urinary incontinence, and urinary irritation and obstruction).

Results

Results from the fully adjusted analyses indicated that non-Hispanic black men were more likely to be above the sample median on the sexual (odds ratio [OR] = 1.43, 95% CI = 1.09–1.88), hormonal (OR = 1.35, 95% CI = 1.03–1.77), and urinary irritation and obstruction (OR = 1.34, 95% CI = 1.03–1.74) domains compared with non-Hispanic white men. The Asian or Pacific Islander men were less likely to be above the sample median on the sexual domain (OR = 0.60, 95% CI = 0.44–0.83) compared with non-Hispanic white men. No additional statistically significant differences were identified.

Conclusions

Within an integrated health care organization, we found minimal racial and ethnic differences, aside from sexual function, in pretreatment HRQOL in men newly diagnosed with prostate cancer. These findings provide important insight with which to interpret HRQOL changes in men newly diagnosed with prostate cancer during and after prostate cancer treatment.

Reading SR, Porter KR, Slezak JM, et al. Racial and Ethnic Variation in Health-Related Quality of Life Scores Prior to Prostate Cancer Treatment. Sex Med 2017;5:e219–e228.

Safety of Quadrivalent Meningococcal Conjugate Vaccine in 11- to 21-Year-Olds

BACKGROUND

Meningococcal conjugate vaccination is recommended in the United States. This study evaluates the safety of quadrivalent meningococcal conjugate vaccine in a cohort aged 11 to 21 years.

METHODS

This cohort study with self-controlled case-series analysis was conducted at Kaiser Permanente Southern California. Individuals receiving MenACWY-CRM, a quadrivalent meningococcal conjugate vaccine, during September 30, 2011 to June 30, 2013, were included. Twenty-six prespecified events of interest (EOIs), including neurologic, rheumatologic, hematologic, endocrine, renal, pediatric, and pediatric infectious disease EOIs, were identified through electronic health records 1 year after vaccination. Of these, 16 were reviewed by case review committees. Specific risk and comparison windows after vaccination were predefined for each EOI. The relative incidence (RI) and 95% confidence intervals (CIs) were estimated through conditional Poisson regression models, adjusted for seasonality.

RESULTS

This study included 48 899 vaccinated individuals. No cases were observed in the risk window for 14 of 26 EOIs. The RI for Bell's palsy, a case review committee-reviewed EOI, was statistically significant (adjusted RI: 2.9, 95% CI: 1.1-7.5). Stratified analyses demonstrated an increased risk for Bell's palsy in subjects receiving concomitant vaccines (RI = 5.0, 95% CI = 1.4-17.8), and no increased risk for those without concomitant vaccine (RI = 1.1, 95% CI = 0.2-5.5).

CONCLUSIONS

We observed a temporal association between occurrence of Bell's palsy and receipt of MenACWY-CRM concomitantly with other vaccines. The association needs further investigation as it could be due to chance, concomitant vaccination, or underlying medical history predisposing to Bell's palsy.

Racial and ethnic variation in baseline health-related quality of life scores prior to prostate cancer treatment

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Background: To compare the racial and ethnic variations in baseline health-related quality of life (HRQOL) scores among men newly-diagnosed with prostate cancer prior to their prostate cancer treatment. Methods: Male members of the Kaiser Permanente of Southern California (KPSC) health plan, newly-diagnosed with prostate cancer, completed the five-domain specific Expanded Prostate Index Composite (EPIC-26) health-related quality of life (HRQOL) questionnaire between March 1, 2011 and August 31, 2013 (n=2,225). The five EPIC-26 domain scores (sexual, bowel, hormonal, urinary incontinence and urinary irritation) were compared across racial and ethnic subgroups and multiple logistic regression analyses were used to assess the association, adjusting for socio-demographic and clinical characteristics. Results: Within each racial and ethnic subgroup,higher baseline HRQOL scores were seen on the bowel, hormonal, urinary incontinence and urinary irritation domains (median score range: 87.5 – 100) as compared to the sexual domain (median score range: 49.3 – 62.5). Asian or Pacific Islander men were less likely to be above the sample median on the sexual (OR=0.51; 95% CI [0.36, 0.74]; p<0.001) and urinary incontinence domains (OR=0.65; 95% CI [0.46, 0.92]; p=0.015) as compared to the non-Hispanic white men. No additional statistically significant differences (p<0.05) were identified. Conclusions: These data suggest that few differences exist in baseline HRQOL scores across racial and ethnic subgroups among men newly-diagnosed with prostate cancer in an integrated health care organization. This finding provides important insight into the pre-treatment HRQOL status among these men with which to interpret HRQOL changes during and after prostate cancer treatment.

Comparison of biochemical failure rates between permanent prostate brachytherapy and radical retropubic prostatectomy as a function of posttherapy PSA nadir plus 'X'

Background

Prostate-specific antigen (PSA) nadir + 2 ng/mL, also known as the Phoenix definition, is the definition most commonly used to establish biochemical failure (BF) after external beam radiotherapy for prostate cancer management. The purpose of this study is to compare BF rates between permanent prostate brachytherapy (PPB) and radical retropubic prostatectomy (RRP) as a function of PSA nadir plus varying values of X and examine the associated implications.

Methods and materials

We retrospectively searched for patients who underwent PPB or RRP at our institution between 1998 and 2004. Only primary patients not receiving androgen-deprivation therapy were included in the study. Three RRP patients were matched to each PPB patient on the basis of prognostic factors. BF rates were estimated for PSA nadirs + different values of X.

Results

A total of 1,164 patients were used for analysis: 873 in the RRP group and 291 in the PPB group. Patients were equally matched by clinical stage, biopsy Gleason sum, primary Gleason grade, and pretherapy PSA value. Median follow-up was 3.1 years for RRP patients and 3.6 years in the PPB group (P = .01). Using PSA nadir + 0.1 ng/mL for the definition of BF, the 5-year BF rate was 16.3% for PPB patients and 13.5% for RRP patients (P = .007), whereas at nadir + 2 ng/mL or greater, the BF rates were less than 3% and were indistinguishable between PPB and RRP patients.

Conclusions

In a cohort of well-matched patients who had prostatectomy or brachytherapy, we examined BF as a function of nadir + X, where X was treated as a continuous variable. As X increases from 0.1 to 2.0 ng/mL, the BF curves converge, and above 2.0 ng/mL they are essentially indistinguishable. The data presented are of interest as BF definitions continue to evolve.

Effects of physical activity and sedentary time on the risk of heart failure

BACKGROUND

Although the benefits of physical activity for risk of coronary heart disease are well established, less is known about its effects on heart failure (HF). The risk of prolonged sedentary behavior on HF is unknown.

METHODS AND RESULTS

The study cohort included 82 695 men aged≥45 years from the California Men's Health Study without prevalent HF who were followed up for 10 years. Physical activity, sedentary time, and behavioral covariates were obtained from questionnaires, and clinical covariates were determined from electronic medical records. Incident HF was identified through International Classification of Diseases, Ninth Revision codes recorded in electronic records. During a mean follow-up of 7.8 years (646 989 person-years), 3473 men were diagnosed with HF. Controlling for sedentary time, sociodemographics, hypertension, diabetes mellitus, unfavorable lipid levels, body mass index, smoking, and diet, the hazard ratio (95% confidence interval [CI]) of HF in the lowest physical activity category compared with those in the highest category was 1.52 (95% CI, 1.39-1.68). Those in the medium physical activity category were also at increased risk (hazard ratio, 1.17 [95% CI, 1.06-1.29]). Controlling for the same covariates and physical activity, the hazard ratio (95% CI) of HF in the highest sedentary category compared with the lowest was 1.34 (95% CI, 1.21-1.48). Medium sedentary time also conveyed risk (hazard ratio, 1.13 [95% CI, 1.04-1.24]). Results showed similar trends across white and Hispanic subgroups, body mass index categories, baseline hypertension status, and prevalent coronary heart disease.

CONCLUSIONS

Both physical activity and sedentary time may be appropriate intervention targets for preventing HF.

Surveillance of autoimmune conditions following routine use of quadrivalent human papillomavirus vaccine

OBJECTIVE

An observational safety study of the quadrivalent human papillomavirus vaccine (HPV4) in women was conducted. This report presents findings from autoimmune surveillance. Design.  Subjects were followed for 180days after each HPV4 dose for new diagnoses of 16 prespecified autoimmune conditions.

SETTING

Two managed care organizations in California. Subjects.  Number of 189,629 women who received ≥1 dose of HPV4 between 08/2006 and 03/2008.

OUTCOME

Potential new-onset autoimmune condition cases amongst HPV4 recipients were identified by electronic medical records. Medical records of those with ≥12-month health plan membership prior to vaccination were reviewed by clinicians to confirm the diagnosis and determine the date of disease onset. The incidence of each autoimmune condition was estimated for unvaccinated women at one study site using multiple imputations and compared with that observed in vaccinated women. Incidence rate ratios (IRR) were calculated. Findings were reviewed by an independent Safety Review Committee (SRC).

RESULTS

Overall, 1014 potential new-onset cases were electronically identified; 719 were eligible for case review; 31-40% were confirmed as new onset. Of these, no cluster of disease onset in relation to vaccination timing, dose sequence or age was found for any autoimmune condition. None of the estimated IRR was significantly elevated except Hashimoto's disease [IRR=1.29, 95% confidence interval: 1.08-1.56]. Further investigation of temporal relationship and biological plausibility revealed no consistent evidence for a safety signal for autoimmune thyroid conditions. The SRC and the investigators identified no autoimmune safety concerns in this study.

CONCLUSIONS

No autoimmune safety signal was found in women vaccinated with HPV4.

Impact of median lobe anatomy: does its presence affect surgical margin rates during robot-assisted laparoscopic prostatectomy?

PURPOSE

To measure and describe the impact of median lobe anatomy on surgical margin status after robot-assisted laparoscopic prostatectomy (RALP).

PATIENTS AND METHODS

We prospectively collected median lobe status, surgical margin status, and other perioperative data on 791 patients who underwent RALP at our institution by 12 surgeons between August 2008 and December 2010. We performed univariable and multivariable analysis to measure the association between median lobe status and positive surgical margin rates, including site.

RESULTS

Compared with patients without a median lobe (n=672), patients with a median lobe (n=119) were less likely to have a positive surgical margin (16% vs 24.4%). They had a higher prostate-specific antigen (PSA) level (6.1 ng/dL vs 5.4 ng/dL), lower Gleason scores (<7, 58.1% vs 42.1%), lower pathologic stages (T(2), 87.4% vs 75.4%), and larger prostates (64 g vs 48 g) (all P<0.05). In our multivariable model, the effect of median lobe anatomy on surgical margin status, after adjusting for these factors, was not statistically significant (relative risk 0.97, 95% confidence interval, 0.64-1.47, P=0.88). Lower PSA level, Gleason score, and pathologic stage and larger prostates, however, predicted decreased positive surgical margin rates (P<0.01).

CONCLUSION

Although presence of median lobe anatomy is not an independent predictor of positive surgical margins in RALP, it is associated with favorable pathologic characteristics that are known to predict decreased positive surgical margins.

Regular nonsteroidal anti-inflammatory drug use and erectile dysfunction

PURPOSE

Previous data suggest a potential relationship between inflammation and erectile dysfunction. If it is causal, nonsteroidal anti-inflammatory drug use should be inversely associated with erectile dysfunction. To this end we examined the association between nonsteroidal anti-inflammatory drug use and erectile dysfunction in a large, ethnically diverse cohort of men enrolled in the California Men's Health Study.

MATERIALS AND METHODS

This prospective cohort study enrolled male members of the Kaiser Permanente managed care plans who were 45 to 69 years old beginning in 2002. Erectile dysfunction was assessed by questionnaire. Nonsteroidal anti-inflammatory drug exposure was determined by automated pharmacy data and self-reported use.

RESULTS

Of the 80,966 men in this study 47.4% were considered nonsteroidal anti-inflammatory drug users based on the definitions used and 29.3% reported moderate or severe erectile dysfunction. Nonsteroidal anti-inflammatory drug use and erectile dysfunction strongly correlated with age with regular drug use increasing from 34.5% in men at ages 45 to 49 years to 54.7% in men 60 to 69 years old with erectile dysfunction increasing from 13% to 42%. The unadjusted OR for the association of nonsteroidal anti-inflammatory drugs and erectile dysfunction was 2.40 (95% CI 2.27, 2.53). With adjustment for age, race/ethnicity, smoking status, diabetes mellitus, hypertension, hyperlipidemia, peripheral vascular disease, coronary artery disease and body mass index, a positive association persisted (adjusted OR 1.38). The association persisted when using a stricter definition of nonsteroidal anti-inflammatory drug exposure.

CONCLUSIONS

These data suggest that regular nonsteroidal anti-inflammatory drug use is associated with erectile dysfunction beyond what would be expected due to age and comorbidity.

Pneumococcal vaccination and risk of acute myocardial infarction and stroke in men

CONTEXT

Multiple studies have shown that preventing influenza by vaccination reduces the risk of vascular events. However, the effect of pneumococcal polysaccharide vaccine on vascular events remains controversial.

OBJECTIVE

To examine the association between pneumococcal vaccination and risk of acute myocardial infarction (MI) and stroke among men.

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort study of Kaiser Permanente Northern and Southern California health plans with 84 170 participants aged 45 to 69 years from the California Men's Health Study who were recruited between January 2002 and December 2003, and followed up until December 31, 2007. The cohort was similar to the population of health plan members and men who responded to a general health survey in California on important demographic and clinical characteristics. Demographic and detailed lifestyle characteristics were collected from surveys. Vaccination records were obtained from the Kaiser Immunization Tracking System.

MAIN OUTCOME MEASURE

Incidence of acute MI and stroke during the follow-up period in men who had no history of such conditions.

RESULTS

During follow-up, there were 1211 first MIs in 112,837 vaccinated person-years (10.73 per 1000 person-years) compared with 1494 first MI events in 246,170 unvaccinated person-years (6.07 per 1000 person-years). For stroke, there were 651 events in 122,821 vaccinated person-years (5.30 per 1000 person-years) compared with 483 events in 254,541 unvaccinated person-years (1.90 per 1000 person-years). With propensity score adjustment, we found no evidence for an association between pneumococcal vaccination and reduced risk of acute MI (adjusted hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.98-1.21) or stroke (adjusted HR, 1.14; 95% CI, 1.00-1.31). An inverse association was also not found in men of different age and risk groups. The results appeared to be consistent, because using more specific International Classification of Diseases, Ninth Revision codes for the outcome definition did not change the estimations.

CONCLUSION

Among a cohort of men aged 45 years or older, receipt of pneumococcal vaccine was not associated with subsequent reduced risk of acute MI and stroke.

Locally recurrent prostate cancer after initial radiation therapy: a comparison of salvage radical prostatectomy versus cryotherapy

PURPOSE

We compared the treatment outcomes of salvage radical prostatectomy and salvage cryotherapy for patients with locally recurrent prostate cancer after initial radiation therapy.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of patients who underwent salvage radical prostatectomy at the Mayo Clinic between 1990 and 1999, and those who underwent salvage cryotherapy at M. D. Anderson Cancer Center between 1992 and 1995. Eligibility criteria were prostate specific antigen less than 10 ng/ml, post-radiation therapy biopsy showing Gleason score 8 or less and prior radiation therapy alone without pre-salvage or post-salvage hormonal therapy. We assessed the rates of biochemical disease-free survival, disease specific survival and overall survival in each group. Biochemical failure was assessed using the 2 definitions of 1) prostate specific antigen greater than 0.4 ng/ml and 2) 2 increases above the nadir prostate specific antigen.

RESULTS

Mean followup was 7.8 years for the salvage radical prostatectomy group and 5.5 years for the salvage cryotherapy group. Compared to salvage cryotherapy, salvage radical prostatectomy resulted in superior biochemical disease-free survival by both definitions of biochemical failure (prostate specific antigen greater than 0.4 ng/ml, salvage cryotherapy 21% vs salvage radical prostatectomy 61% at 5 years, p <0.001; 2 increases above nadir with salvage cryotherapy 42% vs salvage radical prostatectomy 66% at 5 years, p = 0.002) and in superior overall survival (at 5 years salvage cryotherapy 85% vs salvage radical prostatectomy 95%, p = 0.001). There was no significant difference in disease specific survival (at 5 years salvage cryotherapy 96% vs salvage radical prostatectomy 98%, p = 0.283). After adjusting for post-radiation therapy biopsy Gleason sum and pre-salvage treatment serum prostate specific antigen on multivariate analysis salvage radical prostatectomy remained superior to salvage cryotherapy for the end points of any increase in prostate specific antigen greater than 0.4 ng/ml (HR 0.24, p <0.0001), 2 increases in prostate specific antigen (HR 0.47, p = 0.02) and overall survival (HR 0.21, p = 0.01).

CONCLUSIONS

Young, healthy patients with recurrent prostate cancer after radiation therapy should consider salvage radical prostatectomy as it offers superior biochemical disease-free survival and may potentially offer the best chance of cure.

Population-based case-control study of PSA and DRE screening on prostate cancer mortality

OBJECTIVES

The efficacy of screening for prostate cancer (PCa) with digital rectal examination (DRE) and prostate-specific antigen (PSA) measurement has not been proved in randomized clinical trials. In an earlier case-control study, we found that DRE might reduce PCa mortality. The present case-control study assessed the association between PSA and DRE testing and PCa mortality.

METHODS

The case subjects included 74 Olmsted County residents who had died from 1992 to 2005 with PCa as the underlying cause of death. From 1 to 3 community control subjects (alive at time of case subject's death) were matched to each case subject. The medical records were reviewed to identify DREs and PSA determinations performed 0 to 5 years before the date the case was diagnosed (index date). Tests performed in the absence of symptoms were considered to be "screening tests." Conditional logistic regression analysis was used to estimate the odds ratios and 95% confidence intervals for the association of screening (defined in multiple ways) and PCa mortality.

RESULTS

From 1 to 5 years before the index date, control subjects were more likely than case subjects to have undergone a previous screening PSA test or DRE (81.3% versus 60.8%, P = 0.0005). The unadjusted odds ratio associated with a previous screening PSA test or DRE was 0.34 (95% confidence interval 0.18 to 0.63), and the odds ratio adjusted for potential confounders was 0.35 (95% confidence interval 0.17 to 0.71). PSA testing was frequently done in conjunction with DRE, making evaluation of the individual effects difficult.

CONCLUSIONS

The results of this case-control study suggest a potential benefit of screening by PSA testing and/or DRE on PCa mortality.

Diagnosis of obesity by primary care physicians and impact on obesity management

OBJECTIVE

To evaluate whether primary care physicians document obesity as a diagnosis and formulate a management plan.

PATIENTS AND METHODS

The Mayo Clinic primary care database was used to identify general medical examinations performed from November 1, 2004, to October 31, 2005, in a primary care clinic for obese patients (body mass index [BMI] equals 30). Data on demographic variables, BMI, comorbidities, documentation of obesity, and obesity management strategy were obtained through the database. Multivariate logistic regression analyses were conducted to estimate multivariate odds ratios (ORs) and 95 percent confidence intervals (CIs).

RESULTS

A total of 9827 patients were seen for a general medical examination. Of the 2543 obese patients, 505 (19.9 percent) had a diagnosis of obesity documented, and 574 (22.6 percent) had an obesity management plan documented. Older patients (OR, 0.97 per year; 95 percent CI, 0.96-0.98) and men (OR, 0.60; 95% CI, 0.47-0.76) were significantly less likely to be diagnosed as having obesity, whereas those with a BMI greater than 35 (OR, 2.54; 95 percent CI, 2.10-3.16), diabetes mellitus (OR, 1.40; 95 percent CI, 1.09-1.78), and obstructive sleep apnea (OR, 2.34; 95 percent CI, 1.79 to 3.07) were significantly more likely to have the diagnosis made. Staff physicians were less likely than residents to document obesity as a diagnosis (OR, 0.55; 95 percent CI, 0.44 to 0.69). Diagnosis of obesity was the strongest predictor of formulation of an obesity plan (OR, 2.39; 95 percent CI, 1.90 to 3.02).

CONCLUSION

Most obese patients did not have a diagnosis of obesity or an obesity management plan made by their primary care physician. Diagnosis of obesity results in a higher chance of formulation of an obesity plan.

Is the GPSM Scoring Algorithm for Patients With Prostate Cancer Valid in the Contemporary Era?

PURPOSE

The GPSM (Gleason, prostate specific antigen, seminal vesicle and margin status) scoring algorithm is a user friendly model for predicting biochemical recurrence following radical retropubic prostatectomy. It was developed from patients who underwent radical retropubic prostatectomy from 1990 to 1993. We investigated the predictive ability of GPSM in the contemporary era.

MATERIALS AND METHODS

We identified 2,728 patients who underwent radical retropubic prostatectomy for prostate cancer from 1997 to 2000 at our institution. Cox proportional hazard regression models were used to develop multivariate scoring algorithms. Harrell's measure of concordance was used to compare the competing models.

RESULTS

In the contemporary era each GPSM feature remained significantly associated with biochemical recurrence in a multivariate model (each p <0.001). Harrell's measure of concordance for the algorithm was 0.706 vs 0.718 in the original study. After adjusting for GPSM on multivariate analysis Gleason primary 4/5 (p <0.001), DNA ploidy (p = 0.018) and tumor size (p <0.001) were associated with biochemical recurrence. However, none of these features increased Harrell's measure of concordance greater than 0.01 when added to the GPSM model. In addition, using the original 1990 to 1993 cohort, 495 patients with a GPSM score of 10 or greater were significantly more likely to die of prostate cancer compared with 2,169 with a GPSM score of less than 10 (at 15 years 13% vs 2%, HR 6.5, p <0.001).

CONCLUSIONS

The GPSM scoring algorithm is a simple predictive model that remains associated with biochemical recurrence in the contemporary era. In addition, to our knowledge the GPSM algorithm is the first nomogram associated with survival in patients with prostate cancer.

Correlating routine cytology, quantitative nuclear morphometry by digital image analysis, and genetic alterations by fluorescence in situ hybridization to assess the sensitivity of cytology for detecting pancreatobiliary tract malignancy

Routine cytologic (RC), fluorescence in situ hybridization (FISH), digital image analysis (DIA), and quantifiable morphometric results from 284 pancreatobiliary stricture brushings were compared. We chose specific DIA nuclear features assessed by pathologists in evaluating RC specimens, such as area and shape. A visual nuclear morphometric score (VNMS) was calculated. There was a difference (P < .001) in the mean VNMS when RC results were classified as negative (11.5), atypical (12.5), suspicious (13.8), and positive (16.5). The mean VNMS of specimens diagnosed as disomy (11.3), trisomy 7 (12.1), and polysomy (14.7) by FISH was also different (P < .001). There was no difference in the VNMS of false-negative and true-negative cytologic specimens (P = .225). Our findings substantiate the relationship between cell nuclear visual alterations and genetic FISH abnormalities. The low sensitivity of cytologic examination for pancreatobiliary carcinoma is due to an absence of tumor cells or the presence of well-differentiated tumor lacking recognizable nuclear atypia.

Stratification of patient risk based on prostate-specific antigen doubling time after radical retropubic prostatectomy

OBJECTIVE

To assess the risk of local recurrence, systemic progression, and death from cancer among patients who experience biochemical relapse after radical retropubic prostatectomy and to stratify those patients by prostate-specific antigen (PSA) doubling time (DT).

PATIENTS AND METHODS

We identified patients who experienced biochemical recurrence (defined as a PSA level < or =0.4 ng/mL) after radical prostatectomy from January 1, 1990, to December 31, 1999, for prostate adenocarcinoma. The PSA-DT was calculated by log linear regression using all PSA values within 2 years of biochemical recurrence. Local recurrence- and systemic progression- free survival and cancer-specific survival were estimated using the Kaplan-Meier method and analyzed by the log-rank test and Cox models.

RESULTS

Biochemical recurrence was noted in 1521 (27%) of 5533 men during the follow-up period. Of the 1064 patients with a calculable PSA-DT, 322 (30%) had a PSA-DT of less than 1 year, 357 (34%) had a PSA-DT of 1 to 9.9 years, and 385 (36%) had a PSA-DT of 10 years or more. Patients with a PSA-DT of 10 years or more were less likely to have a higher preoperative PSA level, Gleason score, advanced pathologic stage, and seminal vesicle invasion. Patients with a PSA-DT of 10 years or more were at low risk of local recurrence (hazard ratio [HR], 0.09; 95% confidence interval [CI], 0.06-0.14; compared with patients with a PSA-DT of <1 year), systemic progression (HR, 0.05; 95% CI, 0.02-0.13), or death from cancer (HR, 0.15; 95% CI, 0.05-0.43).

CONCLUSIONS

Prostate-specific antigen DT is an independent predictor of clinical disease recurrence and mortality after surgical biochemical failure. Risk stratification into high-, intermediate-, and low-risk categories based on the PSA-DT provides helpful clinical information and assists in the development of salvage therapy trials.

Assessment of changes in kidney allograft function using creatinine-based estimates of glomerular filtration rate

These analyses assessed whether creatinine based estimates of glomerular filtration rate (eGFR) accurately represent (1) graft function at different times post-transplant and (2) changes in function over time. These analyses compared iothalamate GFR to eGFR in 684 kidney allograft recipients. Changes in graft function over time (GFR slope) were measured in 360 of 459 recipients (78%) who were followed for at least 3 years. Ninety-five percent of the patients were Caucasians and 72% received kidneys from living donors. All eGFR calculations correlated significantly with GFR at all time points. However, eGFR were less precise and less accurate during the first-year post-transplant than thereafter. The average rate of GFR change (slope) was -2.93 +/- 11.3%/year (-1.06 +/- 5.3 mL/min/1.73 m(2)/year). Fifty-four percent of patients had stable or positive GFR slopes. The GFR and eGFR slopes were highly correlated. However, eGFR slope, particularly when calculated by MDRD, significantly underestimated the number of patients with declining graft function. For example, 165 out of 360 patients (46%) lost GFR faster than -1 mL/min/1.73 m(2)/year. eMDRD identified only 83 of these patients (50%) while the eMayo formula identified 134 (81%). In conclusion, eGFR correlate with GFR but they have relatively low precision and accuracy particularly early post-transplant. eGFR slopes underestimate graft functional loss although some formulas are significantly better than others for this calculation.

Diabetes mellitus and the risk of urinary tract stones: a population-based case-control study

BACKGROUND

Because nephrolithiasis has been associated with obesity, an important risk factor for type 2 diabetes mellitus (DM), we tested the hypothesis that DM prevalence is increased in individuals who develop renal stones.

METHODS

In an initial electronic analysis, prior diagnoses of DM, hypertension, and obesity were compared between all Olmsted County, MN, residents with a diagnosis code for nephrolithiasis between 1980 and 1999 and matched residents of similar age and sex (N = 3,561 case-control pairs). A random sample of 260 cases and corresponding controls was selected for detailed medical record review to confirm and characterize the stone event and obtain heights, weights, blood pressures, and glucose and cholesterol values.

RESULTS

In the electronic analysis, unadjusted odds ratios (ORs) for DM (OR, 1.29; 95% confidence interval [CI], 1.09 to 1.53), obesity (OR, 1.15; 95% CI, 1.02 to 1.31), and hypertension (OR, 1.19; 95% CI, 1.04 to 1.35) were increased significantly for nephrolithiasis cases versus controls; DM remained significant after adjustment for age, sex, calendar year, hypertension, and obesity (OR, 1.22; 95% CI, 1.03 to 1.46). Detailed record review of a subset showed significant increases for cases versus controls for body mass index (OR, 1.05; 95% CI, 1.01 to -1.09) and hypertension (OR, 1.71; 95% CI, 1.17 to 2.59). Odds for DM were increased, but not significantly, in the subsample (OR, 1.44; 95% CI, 0.76 to 2.72). Among cases with stone analyses, those with uric acid stones (n = 10) had a greater percentage of DM compared with those with all other stone types (n = 112; 40% versus 9%; P = 0.02).

CONCLUSION

Findings from this population-based study suggest that DM, obesity, and hypertension are associated with nephrolithiasis, and DM may be a factor in the development of uric acid stones.

Radical prostatectomy for octogenarians: How old is too old?

OBJECTIVES

As the population ages, healthy octogenarians are increasingly diagnosed with prostate cancer. Some of these patients will request radical prostatectomy (RP), although outcome data in this population group are lacking. We report our experience with patients undergoing RP during their ninth decade of age.

METHODS

From 1986 to 2003, 13,154 patients underwent RP at our institution. Of these patients, 19 (0.14%) were 80 years old or older at surgery and were included in this analysis. Patient survival and quality-of-life measures were retrospectively obtained from the Mayo Clinic Prostatectomy Registry.

RESULTS

The reasons for RP varied, but usually patients requested or demanded operative intervention. At surgery, the mean patient age was 81 years (range 80 to 84), the median prostate-specific antigen level was 10.2 ng/mL (range 1.3 to 45.9), and the mean American Society of Anesthesiologists score was 2.4 (range 2 to 3). Of the 19 patients, 13 (68%) had Stage pT3 disease or a Gleason score of 7 or more. The median follow-up was 10.5 years (range 1.2 to 14.2). At the last follow-up visit, 10 patients had survived more than a decade after RP and 3 patients had died within 10 years of surgery. The remaining 6 patients were alive at less than 10 years of follow-up. Of the 19 patients, 14 (74%) were continent; 1 patient required an artificial sphincter. No patient had died of prostate cancer, and the 10-year all-cause survival rate was similar to that observed in healthy patients 60 to 79 years old undergoing RP.

CONCLUSIONS

On rare occasions, healthy and well-informed octogenarians will request RP for prostate cancer treatment. Our data suggest that select patients can achieve satisfactory oncologic and functional outcomes after surgery, although the rate of urinary incontinence is increased compared with that in younger counterparts.

Obesity and survival after radical prostatectomy: A 10-year prospective cohort study

BACKGROUND

Obesity and prostate cancer are among the most common health problems affecting American men today. The authors' goal was to assess the impact of obesity on clinical and pathologic features of prostate cancer and long-term outcomes.

METHODS

The authors performed a prospective cohort study on 5313 men who underwent radical prostatectomy between 1990 and 1999. Patient height and weight were measured at the time of surgery to calculate the body mass index (BMI). The patients were separated into 3 BMI groups: BMI <25, 25-29.9, and > or =30 kg/m2. The associations between BMI and age, prostate-specific antigen (PSA) level, and Gleason score were assessed with the Spearman rank correlation test. The associations between BMI and pathologic features were assessed with the Mantel-Haenszel chi 2 test. Fifteen-year biochemical progression-free survival, systemic progression-free survival, cancer-specific survival, and overall survival were estimated using the Kaplan-Meier method and evaluated using Cox models. RESULTS.: The median length of follow-up for the entire cohort was 10.1 years. Clinical and pathologic features appear worse in patients with a higher BMI. On univariate and multivariate analyses, it was found that BMI had no impact on biochemical progression, systemic progression, prostate cancer survival, or overall survival.

CONCLUSIONS

Obese patients appear to have worse pathologic features at the time of prostatectomy. Despite these features, long-term oncologic outcomes, including cancer-specific survival, remain the same regardless of BMI. BMI appears to influence prostate cancer outcomes at the time of prostatectomy, as evidenced by more aggressive pathologic features. However, after prostatectomy, BMI does not appear to be an independent predictor of recurrence or survival.

Preoperative prostate specific antigen doubling time and velocity are strong and independent predictors of outcomes following radical prostatectomy

PURPOSE

Prostate specific antigen (PSA) is a useful marker for predicting outcomes following treatment for prostate cancer but, given the evolving nature of prostate cancer, there is an ongoing need to refine its use. We assessed preoperative PSA doubling time (PSADT) and PSA velocity (PSAV) as predictors of outcome following radical retropubic prostatectomy (RRP).

MATERIALS AND METHODS

We identified 2,290 men who were treated with RRP for prostate cancer between 1990 and 1999 with multiple preoperative PSA measurements available. PSADT was calculated by log linear regression and PSAV was calculated by linear regression. These parameters were used in preoperative and postoperative multivariate models for the end points of biochemical and clinical progression, and cancer death.

RESULTS

At a median followup of 7.1 years (range 0.1 to 14.5) biochemical progression, clinical progression and death from prostate cancer were observed in 583, 156 and 42 patients, respectively. The HR for death from prostate cancer was 6.22 (95% CI 3.33 to 11.61) in men with PSADT less than 18 months vs 18 or greater and 6.54 (95% CI 3.51 to 12.19) in men with PSAV greater than 3.4 ng/ml yearly vs 3.4 or less. On multivariate analysis adjusting for preoperative or postoperative variables PSADT and PSAV remained significant predictors of each outcome. When assessed jointly, PSAV was significant as a predictor of biochemical progression, while PSADT was a significant predictor of clinical progression and cancer death.

CONCLUSIONS

This study confirms the usefulness of preoperative PSA kinetics for predicting post-RRP outcomes, which may be useful for stratifying patients, so that rational management decisions can be made with respect to observation, intervention and adjuvant treatment. While PSADT maybe biologically more accurate and stronger on multivariate analysis, PSAV is clinically easier to use and a good approximation in the short term.

Outcomes of gleason score 10 prostate carcinoma treated by radical prostatectomy

OBJECTIVES

To evaluate the outcome of radical prostatectomy for the rarest and most poorly differentiated prostate tumors of all: those with Gleason score 10. Controversy exists as to which form of therapy is most effective for high-grade prostate cancer (PCa).

METHODS

We retrospectively reviewed the charts of all patients with pathologic Gleason score 10 PCa treated at our institution with radical prostatectomy from 1977 to 1999. All pathology specimens were reviewed by a urologic pathologist, and 13 cases with true Gleason score 10 PCa were identified. The preoperative covariables (prostate-specific antigen level, biopsy Gleason score, and clinical stage), perioperative covariables (pathologic stage, margin status, and tumor ploidy), and postoperative covariables (prostate-specific antigen level and adjuvant and salvage treatments) were assessed with respect to the oncologic outcomes.

RESULTS

The median follow-up was 4.2 years. Preoperatively, only 4 of the 13 cases were correctly identified at biopsy, and the median preoperative prostate-specific antigen level was 4.5 ng/mL (interquartile range 0.3 to 12.5). Pathologic examination showed a small cell component in 7 cases, seminal vesicle invasion in 11, and positive lymph nodes in 3. Six patients developed recurrent PCa: three local, two systemic, and one biochemical recurrence. The biochemical recurrence-free and cancer-specific survival rate at 5 years was 53.8% and 76.9%, respectively.

CONCLUSIONS

Gleason score 10 PCa is a highly aggressive disease that is usually lethal if managed conservatively. The results of the present study have provided some evidence that radical prostatectomy may be of benefit to patients with Gleason score 10 PCa.

Impact of Familial and Hereditary Prostate Cancer on Cancer Specific Survival After Radical Retropubic Prostatectomy

PURPOSE

Men with a family history of prostate cancer are at higher risk for prostate cancer. There are conflicting data regarding the impact of hereditary forms of prostate cancer on long-term outcomes after radical prostatectomy. We examined the impact of familial and hereditary prostate cancer treatment in the prostate specific antigen era.

MATERIALS AND METHODS

Patients who underwent radical prostatectomy for prostate cancer from 1987 to 1997 were surveyed (3,560 responders) to determine the family history of prostate cancer. Patients were categorized as having familial prostate cancer if they had at least 1 first-degree relative with prostate cancer. Hereditary prostate cancer was defined as nuclear families with 3 cases of prostate cancer, families with prostate cancer in each of 3 generations and families with 2 men diagnosed before age 55 years. Sporadic prostate cancer was defined as patients with no family history. Clinical and pathological features, and long-term outcome measures, including biochemical recurrence-free, systemic progression-free and cancer specific survival, were compared among patients with familial, hereditary and sporadic prostate cancer.

RESULTS

A total of 865 and 133 patients were categorized as having familial prostate cancer and hereditary prostate cancer, respectively. Preoperatively prostate specific antigen was higher in patients with hereditary prostate cancer than in the other 2 groups (p = 0.04). Ten-year biochemical progression-free, systemic progression-free and cancer specific survival were equivalent.

CONCLUSIONS

Except for preoperative prostate specific antigen, clinicopathological features and long-term oncological outcomes are equivalent after radical prostatectomy in patients with familial, hereditary and sporadic prostate cancer.

Can the kidney function as a lung? Systemic oxygenation and renal preservation during retrograde perfusion of the ischaemic kidney in rabbits

OBJECTIVE

To investigate renal preservation by a novel method of perfusion using an oxygenated perfluorocarbon (PFC) emulsion via retrograde access to the kidney, as preserving renal function during urological surgery has been elusive, and the recognized technique of nephron-sparing surgery has increased its application and practice in modern urology.

MATERIALS AND METHODS

After institutional review and approval, 30 New Zealand White rabbits were studied. In a solitary kidney model, each rabbit had the ureter catheterized before 40 min of renal artery occlusion. Each rabbit was randomized to one retrograde perfusion group, i.e. sham, normothermic PFC, chilled PFC, normothermic saline, and chilled saline. The rabbits were maintained for 2 weeks, during which renal function, urine output, systemic blood gases, weight and serum creatinine level were measured. After death, the kidneys were individually examined and graded by one renal pathologist unaware of the treatment.

RESULTS

The rabbits treated with retrograde PFC perfusion (normothermic and chilled) had less change in their creatinine clearance, at 3.6 and 4.0 mL/min per kg, than the sham group, at 7.8 mL/min per kg, while also having significantly higher systemic venous oxygenation, at 26.3 and 10.0 mmHg, than the sham group, at 0.2 mmHg. Normothermic and chilled perfusion with PFC was also associated with less histological evidence of ischaemic damage, with mean (sd) scores of 13.0 (13.5) and 8.7 (4.5), respectively, than in the sham group, at 33.3 (16.8), while favourably matching the contralateral control kidney group, at 5.5 (2.3). The rabbits treated with saline retrograde perfusion also had better outcomes than the sham cohort. There were no adverse effects in any of the study arms or with the use of PFC.

CONCLUSION

Retrograde oxygen delivery to the kidney through the urinary collecting system was successful in this pilot study. Renal function, laboratory and histological data indicate a trend towards renal preservation and even systemic oxygenation in the experimental groups compared with the sham rabbits, with no adverse effects attributed to this technique.

Detectable Prostate Specific Antigen Between 60 and 120 Days Following Radical Prostatectomy for Prostate Cancer: Natural History and Prognostic Significance

PURPOSE

Following radical retropubic prostatectomy for prostate cancer, if the serum prostate specific antigen fails to become undetectable, occult micrometastatic disease is suspected. We assessed the natural history of disease progression, and predictors of recurrence and survival in this group of patients.

MATERIALS AND METHODS

We identified 303 men treated with radical retropubic prostatectomy for prostate cancer between 1990 and 1999, who had a detectable prostate specific antigen between 60 and 120 days postoperatively. Systemic recurrence-free and cancer specific survival were estimated using the Kaplan-Meier method, and analyzed using Cox proportional hazards models.

RESULTS

Clinical and pathological features were more adverse among men whose postoperative prostate specific antigen was detectable. These men had poorer systemic recurrence-free survival and cancer specific survival compared to men with an undetectable postoperative prostate specific antigen, and even men whose prostate specific antigen subsequently became detectable. These differences persisted after multivariate adjustment for preoperative prostate specific antigen, specimen Gleason score, seminal vesicle and margin status. With a median followup of 8.5 years, 50 systemic recurrences and 26 deaths from cancer were observed. Gleason score and the prostate specific antigen doubling time were multivariate predictors of systemic recurrence, while Gleason score, margin status and seminal vesicle invasion were predictors of death from cancer.

CONCLUSIONS

A detectable prostate specific antigen immediately following radical retropubic prostatectomy confers an increased risk of progression and death, but only in a subset of patients, who may be identified on the basis of pathological features and prostate specific antigen doubling time. In future such patients may be suitable for trials of systemic therapy.

Follow-up study of long-term survivors of osteosarcoma in the prechemotherapy era

Osteosarcoma is the most common primary bone sarcoma. Several studies published in the 1960s established that approximately one fifth of patients survive when treated with surgery alone. There is no information, however, about the long-term consequences of osteosarcoma. It is especially relevant to know if these patients are at risk for a second malignancy. We reviewed all clinical records from long-term (defined as more than 10 years) osteosarcoma survivors treated at Mayo Clinic in the prechemotherapeutic era from 1900 to 1960. We re-reviewed histological sections for most cases. Patients or next of kin provided follow-up information during telephone interviews. Rates of second malignancy were compared with expected rates in the population at large. We identified 465 patients treated for osteosarcoma. Of these patients, 83 (17.8%) were long-term survivors, including 19 who were alive up to 65 years after treatment. Of the 7 patients with pulmonary metastases, 3 died. A second malignancy developed in 26 patients, 15 of whom died of the malignancy. Although long-term survivors of osteosarcoma have a higher incidence of a second malignant tumor than a normal population, this increase was not statistically significant. No demographic or histological variables predicted long-term survival.

Renal stone epidemiology in Rochester, Minnesota: an update

Studies in Western countries have suggested an increasing incidence of nephrolithiasis (NL) in the latter part of the 20th century. Therefore, we updated NL epidemiology data for the Rochester population over the years 1970-2000. All Rochester residents with any diagnostic code that could be linked to NL in the years of 1970, 1980, 1990, and 2000 were identified, and the records reviewed to determine if they met the criteria for a symptomatic kidney stone as defined in a previous Rochester, MN study. Age-adjusted incidence (+/-s.e.) of new onset symptomatic stone disease for men was 155.1 (+/-28.5) and 105.0 (+/-16.8) per 100,000 per year in 1970 and 2000, respectively. For women, the corresponding rates were 43.2 (+/-14.0) and 68.4 (+/-12.3) per 100,000 per year, respectively. On average, rates for women increased by about 1.9% per year (P=0.064), whereas rates for men declined by 1.7% per year (P=0.019). The overall man to woman ratio decreased from 3.1 to 1.3 during the 30 years (P=0.006). Incident stone rates were highest for men aged 60-69 years, whereas for women, they plateaued after age 30. Therefore, since 1970 overall NL incidence rates in Rochester have remained relatively flat. However, NL rates for men have declined, whereas rates for women appear to be increasing. The reasons remain to be determined.

Prostate specific antigen doubling time subsequent to radical prostatectomy as a prognosticator of outcome following salvage radiotherapy

PURPOSE

Therapy for men with detectable prostate specific antigen (PSA) following radical prostatectomy (RP) for prostate cancer remains controversial. Salvage radiotherapy (SRT) is commonly used because of its relatively low morbidity. We present a single institution retrospective review of patients treated with SRT.

MATERIALS AND METHODS

A longitudinal cohort study (between April 1987 and April 2000) using the referral based Mayo Clinic Prostate Cancer Registry was conducted. A total of 211 patients were included in this study if detectable serum PSA was the sole indication for SRT and no hormonal therapy was administered.

RESULTS

Median followup from surgery to death or last followup was 7.2 years, from RP to SRT was 1.7 years and from SRT to last contact was 4.2 years. Median PSA and prostate specific antigen doubling time (PSADT) at SRT initiation was 0.60 ng/ml and 7.32 months; respectively. Of the patients 90% had nadir PSA less than 0.4 ng/ml within 3 years of SRT. Biochemical disease-free rates at 5 years for PSADT less than 12 or 12 months or greater was 48% and 66%; respectively (p = 0.080). By 10 years there was no significant difference in biochemical disease-free rate (34% vs 35%). Clinical metastasis (10% and 29%) developed in patients with a PSADT less than 12 months at a significantly higher rate than in patients with a PSADT of 12 months or more (0% and 17%, p = 0.045) at 5 and 10 years, respectively. Multivariate analysis revealed pre-SRT PSADT (less than 12 months, H.R. 3.88, p = 0.032), seminal vesicle invasion (H.R. 3.22, p = 0.008), pathological grade (H.R. 1.58, p = 0.023) and PSA at SRT (H.R. 1.29 for a 2-fold increase, p = 0.044) to be significant independent predictors of clinical recurrence. The interval from RP to SRT did not add to the model (p = 0.22).

CONCLUSIONS

A biochemical response can be expected in the majority of patients within 3 years of receiving SRT. Patients with a pre-SRT PSADT of 1 year or less have a less sustained biochemical response to SRT than patients with a PSADT greater than 1, yet the majority of patients appear to receive long-term benefit from this adjunctive therapy. PSADT is an independent predictor of biochemical and clinical disease recurrence following SRT.

Impact of Patient Age at Treatment on Outcome Following Radical Retropubic Prostatectomy for Prostate Cancer

PURPOSE

Historically young patients with prostate cancer have been found to have poorer outcomes. Recent studies suggest favorable pathological findings and improved survival in younger patients undergoing RRP. We assessed age at treatment as a predictor of post-RRP survival.

MATERIALS AND METHODS

We identified 5,509 patients treated with RRP for prostate cancer at our institution between 1987 and 1995. Age at treatment was classified into categories of younger than 55, 55 to 59, 60 to 64, 65 to 69 and 70 years or older. CSS, sPFS and biochemical PFS were estimated by the Kaplan-Meier method and analyzed using Cox proportional hazard models.

RESULTS

Younger patients had lower preoperative prostate specific antigen, and tumor grade and stage. CSS, sPFS and biochemical PFS were similar across age groups but overall survival decreased with older age at treatment. After multivariate adjustment the risk of cancer death was lower in patients 70 years or older (RR 0.53, 95% CI 0.30 to 0.90), while the risk of progression was lower in all age groups compared to that in men younger than 55 years (RR 0.57 to 0.62). On stratified subset analysis sPFS was progressively worse with younger age in patients with high risk pathological findings. However, the addition of age to multivariate models incorporating preoperative prostate specific antigen, pathological features and adjuvant therapy failed to improve their predictive value for CSS and sPFS.

CONCLUSIONS

Despite more favorable clinicopathological features younger patients undergoing RRP for prostate cancer have survival similar to that of older counterparts. Given the greater proportionate impact of prostate cancer on survival, it is particularly important to pursue aggressive treatment in younger patients.

Long-term prognostic significance of primary Gleason pattern in patients with Gleason score 7 prostate cancer: impact on prostate cancer specific survival

PURPOSE

We determined the long-term clinical significance of primary Gleason pattern in patients with Gleason score 7 prostate cancer.

MATERIALS AND METHODS

We reviewed the records of all patients who underwent bilateral pelvic lymph node dissection and radical retropubic prostatectomy for Gleason score 7 prostate cancer at our institution. All patients who underwent adjuvant hormonal or radiation therapy were excluded from analysis. Patients were monitored for biochemical failure, that is PSA progression, systemic recurrence and cancer specific survival.

RESULTS

We identified 1,688 patients who met admission criteria, of whom 1,256 (74.4%) had primary Gleason pattern 3 and 432 (25.6%) had primary Gleason pattern 4. Median followup was 6.9 years. At 10 years primary Gleason pattern 3 was associated with increased biochemical recurrence-free survival (48% vs 38%, p <0.001), lower systemic recurrence (8% vs 15%, p <0.001) and higher cancer specific survival (97% vs 93%, p = 0.013) for Gleason primary grades 3 and 4, respectively. All of these end points remained significant on multivariate analysis when controlling for preoperative PSA, seminal vesicle involvement, margin status, DNA ploidy and TNM staging. PSA doubling time was shorter in patients with primary Gleason pattern 4 (1.64 vs 1.01 years). Systemic recurrence and cancer specific survival were associated with a PSA doubling time of less than 1 year.

CONCLUSIONS

Gleason score 7 prostate cancer is a heterogeneous entity. We should continue to stratify patients according to primary Gleason pattern. Patients with Gleason score 4 + 3 prostate cancer have more aggressive disease and experience higher rates of biochemical failure, systemic recurrence and cancer specific death.

Glomerular filtration rate estimated by cystatin C among different clinical presentations

Glomerular filtration rate (GFR) estimates from serum creatinine has not been generalizable across all populations. Cystatin C has been proposed as an alternative marker for estimating GFR. The objective of this study was to compare cystatin C with serum creatinine for estimating GFR among different clinical presentations. Cystatin C and serum creatinine levels were obtained from adult patients (n=460) during an evaluation that included a GFR measurement by iothalamate clearance. Medical records were abstracted for clinical presentation (healthy, native chronic kidney disease or transplant recipient) at the time of GFR measurement. GFR was modeled using the following variables: cystatin C (or serum creatinine), age, gender and clinical presentation. The relationship between cystatin C and GFR differed across clinical presentations. At the same cystatin C level, GFR was 19% higher in transplant recipients than in patients with native kidney disease (P<0.001). The association between cystatin C and GFR was stronger among native kidney disease patients than in healthy persons (P<0.001 for statistical interaction). Thus, a cystatin C equation was derived using only patients with native kidney disease (n=204). The correlation with GFR (r(2)=0.853) was slightly higher than a serum creatinine equation using the same sample (r(2)=0.827), the Modification of Diet in Renal Disease equation (r(2)=0.825) or the Cockcroft-Gault equation (r(2)=0.796). Averaged estimates between cystatin C and serum creatinine equations further improved correlation (r(2)=0.891). Cystatin C should not be interpreted as purely a marker of GFR. Other factors, possibly inflammation or immunosuppression therapy, affect cystatin C levels. While recognizing this limitation, cystatin C may improve GFR estimates in chronic kidney disease patients.

Simple graphic method for estimation of prostate-specific antigen doubling time

The prostate-specific antigen doubling time (PSADT) is of prognostic value in patients with prostate cancer, but computerized algorithms are usually required for PSADT estimation. We present here a simple graphic tool that can be used to estimate the PSADT on the basis of two increasing PSA measurements, separated by 3 to 12 months.

Trends in distribution and prognostic significance of Gleason grades on radical retropubic prostatectomy specimens between 1989 and 2001

BACKGROUND

The objectives of the current study were to examine time trends in the prevalence of Gleason grades of prostate cancer on radical retropubic prostatectomy (RRP) specimens and to assess the resultant impact on prognosis.

METHODS

The authors examined the prevalence over time of each grade and Gleason score (GS) on RRP specimens from 8750 patients who were treated between 1989 and 2001. Biochemical recurrence-free survival (BRFS), which was estimated by using Kaplan-Meier methodology, was examined in subgroups of patients defined by tumor grade and era of surgery.

RESULTS

The prevalence of Grade 3 prostate cancers increased (86% vs. 49% for primary Gleason grade and 71% vs. 47% for secondary Gleason grade; 1999-2001 vs. 1989-1990, respectively), whereas the prevalence of Grade 2 tumors decreased (0.4% vs. 38% for primary Gleason grade and 1.3% vs. 28% for secondary Gleason grade, respectively) over the study period, leading to fewer GS 4 and 5 tumors and more GS 6 and 7 tumors. BRFS improved over time for patients who had GS 5 tumors (hazards ratio [HR], 0.92 per year; P = .003) and GS 6 tumors (HR, 0.93; P < .001) but remained unchanged for GS 7 tumors (HR 0.99; P = .462) and GS 8-10 tumors (HR 1.02; P = .360). Patients who were treated in the recent era (1997-2001) had greater differentiation of BRFS based on GS or Gleason grade compared with patients who were treated earlier (1989-1991).

CONCLUSIONS

The current results confirmed that there were changes in the prevalence of Gleason grades on RRP specimens between 1989 and 2001. A chronological change in pathologic grading classification is suggested by evolving prognostic implications, which must be accounted for when comparing outcomes from different eras.