A 25-year Period Analysis of Other-cause Mortality in Localized Prostate Cancer

BackgroundWe examined the changes over time in other-cause mortality (OCM) rates in patients with clinically localized prostate cancer (PCa) as an indicator of patient selection.Patients and MethodsWithin the Surveillance, Epidemiology, and End Results database (1987-2011), we identified patients with PCa treated with either radical prostatectomy (RP) (n = 230,969; 62.8%) or external beam radiation therapy (EBRT) (n = 136,915; 37.2%). Temporal trends and multivariable Cox regression analyses assessed OCM at 5 years using stratification according to year of diagnosis (1987-1991 vs. 1992-1996 vs. 1997-2001 vs. 2002-2006 vs. 2007-2011), age group, and ethnicity.ResultsIn patients who had undergone RP, the OCM rates at 5 years of follow-up decreased over time from 7.9% to 2.4% (slope, ?0.25%/year) versus from 15.2% to 9.9% after EBRT (slope, ?0.29%/year). The greatest decrease in 5-year OCM rates over time was recorded in patients ≥ 75 years (16.0%-12.0%; slope, ?0.25%/year), followed by younger age categories (70-74 years, ?0.21%/year; 65-69 years, ?0.17%/year; 60-64 years, ?0.10%/year; < 60 years, ?0.07%/year), as well as in African-American men (11.0%-5.1%; slope, ?0.32%/year), followed by Caucasian (7.6%-3.4%; slope, ?0.21%/year) and Hispanic men (7.0%-3.1%; slope, ?0.20%/year; all P < .001), as corroborated in multivariable Cox regression models.ConclusionsOCM rates were highest in oldest individuals and in African-American men. In both groups, an important 5-year OCM reduction over the 25-year study span was recorded. Nonetheless, these 2 patient groups may still represent the ideal target for better patient selection based on OCM considerations, because their most recent OCM rates exceeded those of, respectively, younger and Caucasian patients.     

Variation in Positive Surgical Margin Status After Radical Prostatectomy for pT2 Prostate Cancer

IntroductionWe evaluated patient, hospital, and cancer-specific factors associated with positive surgical margin (PSM) variability after radical prostatectomy in pT2 prostate cancer in the United States.Patients and MethodsA total of 45,426 men from 1152 hospitals with pT2 prostate cancer and known margin status after radical prostatectomy were identified using the National Cancer Database (2010-2015). Data on patient, cancer, hospital factors, and surgical approach were extracted. A mixed effects logistic regression model was computed to examine factors associated with PSM and partial R² values to assess the relative contributions of patient, cancer, and hospital variables to PSM status.ResultsMedian PSM rate of 8.5% (interquartile range, 5.2%-13.0%). Robotic (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.83-0.99) and laparoscopic (OR, 0.74; 95% CI, 0.64-0.90) surgical approach, academic institution (OR, 0.87; 95% CI, 0.76-1.00) and high hospital surgical volume (>297 cases [OR], 0.83; 95% CI, 0.70-0.99) were independently associated with a lower PSM. Black men (OR, 1.13; 95% CI, 1.01-1.26) and adverse cancer-specific features (prostate-specific antigen [PSA], 10-20; PSA >20; cT3 stage; Gleason 7, 8, 9-10; all P > .01) were independently associated with a higher PSM. Patient-specific, hospital-specific, and cancer-specific factors had a contribution of 2.3%, 3.9%, and 15.2%, respectively, to the variation in PSM. Facility had a contribution of 23.7% to the variation in PSM.ConclusionCancer-specific factors account for 15.2% of PSM variation with the remaining 84.8% of PSM variation due to patient, hospital, and other factors not accounted within the model. Noncancer-specific factors represent addressable factors that are important for policy-makers in efforts to improve patient outcome.     

Focal Laser Ablation Versus Radical Prostatectomy for Localized Prostate Cancer: Survival Outcomes From a Matched Cohort

BackgroundFocal therapy for localized prostate cancer (PCa) remains investigational. We aimed to investigate the oncologic outcomes of focal laser ablation (FLA) and compare them with those of radical prostatectomy (RP).Patients and MethodsPatients treated with FLA or RP for localized PCa between 2004 and 2015 were identified from the Surveillance, Epidemiology, and End Results database. Kaplan-Meier curves and multivariate Cox proportional hazard models were utilized to calculate the survival benefits. Propensity score (PS) matching and adjusted standardized mortality ratio weighting (SMRW) models were used to balance the 2 groups. Subgroup analyses according to tumor stage, prostate-specific antigen level, and Gleason score were also conducted.ResultsA total of 12,875 patients were included, of whom 12,433 were treated with RP, whereas 442 were treated with FLA; 321 pairs of patients were eventually matched. Baseline characteristics were well-balanced by PS matching. The mean follow-up was 59.62 months for the RP group and 62.26 months for the FLA group. Before matching, the FLA group had lower but statistically insignificant cancer-specific mortality (CSM) (hazard ratio [HR], 0.61; 95% confidence interval [CI], 0.15-2.45; P = .4879) and higher any-cause mortality (ACM) (HR, 2.35; 95% CI, 1.38-3.98; P = .0016) compared with the RP group, which was supported by the outcomes in the PS-matched cohort (CSM: HR, 0.82; 95% CI, 0.18-3.67; P = .7936; ACM: HR, 2.35; 95% CI, 1.38-3.98; P = .0016) and the SMRW model (CSM: HR, 0.61; 95% CI, 0.15-2.44; P = .4877; ACM: HR, 2.01; 95% CI, 1.18-3.42; P = .0103).ConclusionOur study suggests that FLA had a higher risk of ACM but an insignificantly lower risk of CSM compared with RP. More high-quality trials are needed to confirm and expand our findings.     

Increasing Rate of Noninterventional Treatment Management in Localized Prostate Cancer Candidates for Active Surveillance: A North American Population-Based Study

Background

The rate of noninterventional treatment (NIT) in prostate cancer (PCa) active surveillance (AS) candidates is on the rise. However, contemporary data are unavailable. We described community-based NIT rates within 16 Surveillance Epidemiology and End Results (SEER) registries between 2010 and 2014.

Advancing Age and the Odds of Upgrading and Upstaging at Radical Prostatectomy in Men with Gleason Score 6 Prostate Cancer

PurposeTo identify a subset of men with Gleason score (GS) 6 prostate cancer who are at high risk for upgrading/upstaging who should be recommended for multiparametric magnetic resonance imaging.Patients and MethodsBetween 1992 and 2017, a total of 3571 men with GS6 prostate cancer were consecutively treated at a single institution with radical prostatectomy. Logistic regression multivariable analyses to determine the odds of upgrading and upstaging were performed, adjusting for age and year of diagnosis, clinical T category, prostate-specific antigen level, number of biopsy cores, and percentage of positive biopsy cores.ResultsOf 3571 men, the disease of 115 (3.22%), 245 (6.86%), and 254 (7.11%) was upgraded, was upstaged, or had positive surgical margins (R1), respectively. Older age at diagnosis was associated with an increased risk of upgrading disease to GS7 or higher, prostatectomy T3/T4, and R1 with adjusted odds ratios (95% confidence intervals) of 1.05 (1.01-1.08; P = .005), 1.02 (1.00-1.05; P = .048), and 1.02 (1.002-1.05; P = .03), respectively. Older age was associated with an increasing proportion of men with disease upgraded to GS7 or higher (T1c: P = .002; T2 or higher: P = .04) or upstaged to pT3/4 or pT2R1 (T1c: P = .02; T2 or higher: P = .02) among men with ≥ 33% but not < 33% positive biopsy cores.ConclusionBefore initiating active surveillance, performing multiparametric magnetic resonance imaging in otherwise healthy older men with GS6 prostate cancer and ≥ 33% positive biopsy cores should be considered.     

A National Survey of Radiation Oncologists and Urologists on Perceived Attitudes and Recommendations of Active Surveillance for Low-Risk Prostate Cancer

BackgroundClinical factors and barriers affecting adoption of active surveillance (AS) for low-risk prostate cancer (PCa) remain poorly understood. We performed a national survey of radiation oncologists (RO) and urologists (URO) about the perceptions and recommendations of AS for low-risk PCa.Materials and MethodsIn 2017, we surveyed 915 RO and 940 URO about AS for low-risk PCa in the United States. Survey items queried respondents about their attitudes toward AS and recommendations of AS for low-risk PCa. Pearson chi-square and multivariable logistic regression identified clinical and physician factors related toward AS for low-risk PCa.ResultsOverall, the response rate was 37.3% (n = 691) and was similar for RO and URO (35.7% vs. 38.7%; P = .18). RO were less likely to consider AS effective for low-risk PCa (86.5% vs. 92.0%; P = .04) and more likely to rate higher patient anxiety on AS (49.5% vs. 29.5%; P < .001) than URO. Recommendations of AS varied modestly on the basis of age, prostate-specific antigen (PSA), and number of cores positive for Gleason 3 + 3 PCa. For a 55-year-old man with PSA 8 with 6 cores of Gleason 6 PCa, both RO and URO infrequently recommended AS (4.4% vs. 5.2%; adjusted odds ratio = 0.6; P = .28). For a 75-year-old patient with PSA 4 with 2 cores of Gleason 6 PCa, URO and RO most often recommended AS (89.6% vs. 83.4%; adjusted odds ratio = 0.5; P = .07).ConclusionRO and URO consider AS to be effective in the clinical management of low-risk PCa, but this varies by clinical and physician factors.