Low conflict and high satisfaction: Decisional outcomes after attending a combined clinic to choose between robotic prostatectomy and radiotherapy for prostate cancer

BackgroundDecisional conflict and post-treatment decisional regret have been documented in men with localised prostate cancer (LPC). However, there is limited evidence regarding decisional outcomes associated with the choice between robotic-assisted radical prostatectomy (RARP) and radiotherapy, when both treatment options are available in the public health system. There is increasing support for multidisciplinary approaches to guide men with LPC in their decision-making process. This study assessed decisional outcomes in men deciding between RARP or radiotherapy treatment before and after attending a LPC combined clinic (CC).MethodsQuantitative longitudinal data were collected from 52 men who attended a LPC CC, where they saw both a urologist and radiation oncologist. Patients completed questionnaires assessing involvement in decision-making, decisional conflict, satisfaction and regret before and after the CC, three months, six months and 12 months post-treatment. Urologists and radiation oncologists also reported their perceptions regarding patients' suitability for, openness to, perceived preferences and appropriateness for each treatment. Data was analysed using paired/independent samples t-tests and McNemar's tests.ResultsMost participants (n = 37, 71%) opted for RARP over radiotherapy (n = 14, 27%); one participant deferred treatment (2%). Urologists and radiation oncologists reported low agreement (κ = 0.26) regarding the most appropriate treatment for each patient. Participants reported a desire for high levels of control over their decision-making process (77.5% patient-led, 22.5% shared) and high levels of decisional satisfaction (M = 4.4, SD = 0.47) after the CC. Decisional conflict levels were significantly reduced (baseline: M = 29.3, SD = 16.9, post-CC: M = 16.3, SD = 11.5; t = 5.37, P < 0.001) after the CC. Mean decisional regret scores were ‘mild’ at three-months (M = 16.0, SD = 17.5), six-months (M = 18.8, SD = 18.7) and 12-months (M = 18.2, SD = 15.1) post-treatment completion.ConclusionThis is the first Australian study to assess decisional outcomes when patients are offered the choice between RARP and radiotherapy in the public health system. A CC seems to support decision-making in men with LPC and positively impact some decisional outcomes. However, larger-scale controlled studies are needed to confirm these findings.     

Decision regret,adverse outcomes,and treatment choice in men with localized prostate cancer: Results from a multi-site randomized trial

IntroductionMen diagnosed with localized prostate cancer must navigate a highly preference-sensitive decision between treatment options with varying adverse outcome profiles. We evaluated whether use of a decision support tool previously shown to decrease decisional conflict also impacted the secondary outcome of post-treatment decision regret.MethodsParticipants were randomized to receive personalized decision support via the Personal Patient Profile-Prostate or usual care prior to a final treatment decision. Symptoms were measured just before randomization and 6 months later; decision regret was measured at 6 months along with records review to ascertain treatment choices. Regression modeling explored associations between baseline variables including race and D`Amico risk, study group, and 6-month variables regret, choice, and symptoms.ResultsAt 6 months, 287 of 392 (73%) men returned questionnaires of which 257 (89%) had made a treatment choice. Of that group, 201 of 257 (78%) completely answered the regret scale. Regret was not significantly different between participants randomized to the P3P intervention compared to the control group (P = 0.360). In univariate analyses, we found that Black men, men with hormonal symptoms, and men with bowel symptoms reported significantly higher decision regret (all P < 0.01). Significant interactions were detected between race and study group (intervention vs. usual care) in the multivariable model; use of the Personal Patient Profile-Prostate was associated with significantly decreased decisional regret among Black men (P = 0.037). Interactions between regret, symptoms and treatment revealed that (1) men choosing definitive treatment and reporting no hormonal symptoms reported lower regret compared to all others; and (2) men choosing active surveillance and reporting bowel symptoms had higher regret compared to all others.ConclusionThe Personal Patient Profile-Prostate decision support tool may be most beneficial in minimizing decisional regret for Black men considering treatment options for newly-diagnosed prostate cancer.Trial RegistrationNCT01844999     

Getting back to equal: The influence of insurance status on racial disparities in the treatment of African American men with high-risk prostate cancer

ObjectivesTreating high-risk prostate cancer (CaP) with definitive therapy improves survival. We evaluated whether having health insurance reduces racial disparities in the use of definitive therapy for high-risk CaP.Materials and methodsThe Surveillance, Epidemiology, and End Results Program was used to identify 70,006 men with localized high-risk CaP (prostate-specific antigen level >20 ng/ml or Gleason score 8–10 or stage>cT3a) diagnosed from 2007 to 2010. We used multivariable logistic regression to analyze the 64,277 patients with complete data to determine the factors associated with receipt of definitive therapy.ResultsCompared with white men, African American (AA) men were significantly less likely to receive definitive treatment (adjusted odds ratio [AOR] = 0.60; 95% CI: 0.56–0.64; P<0.001) after adjusting for sociodemographics and known CaP prognostic factors. There was a significant interaction between race and insurance status (P_interaction = 0.01) such that insurance coverage was associated with a reduction in racial disparity between AA and white patients regarding receipt of definitive therapy. Specifically, the AOR for definitive treatment for AA vs. white was 0.38 (95% CI: 0.27–0.54, P<0.001) among uninsured men, whereas the AOR was 0.62 (95% CI: 0.57–0.66, P<0.001) among insured men.ConclusionsAA men with high-risk CaP were significantly less likely to receive potentially life-saving definitive treatment when compared with white men. Having health insurance was associated with a reduction in this racial treatment disparity, suggesting that expansion of health insurance coverage may help reduce racial disparities in the management of aggressive cancers.     

Outcomes in racial and ethnic minorities after revisional robotic-assisted metabolic and bariatric surgery: an analysis of the MBSAQIP database

BackgroundRobotic-assisted metabolic and bariatric surgery (MBS) is being performed with increased frequency in the United States, including for revisional MBS. However, little is known about perioperative outcomes between racial and ethnic cohorts after revisional robotic-assisted MBS.ObjectiveThe goal of our study was to determine if there are racial differences in outcomes after robotic-assisted revisional MBS.SettingUniversity Hospital, United States.MethodsUsing the 2015–2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, we identified patients undergoing revisional MBS by a robotic-assisted approach. Univariate analyses were performed of unmatched and matched racial and ethnic cohorts, comparing black versus white patients and Hispanic versus white patients.ResultsOf 2027 robotic-assisted revisional MBS cases in the database, 1922 were included in our analysis, including 67%, 22.6%, and 10.4% white, black, and Hispanic patients, respectively. At baseline, there were some differences in patient characteristics between racial and ethnic cohorts. After propensity matching, outcomes between black and white patients were similar, except for higher rates of superficial surgical site infection among white patients (P = .05) and higher rates of organ space surgical site infection in black patients (P = .05). Outcomes were also similar between matched white and Hispanic patients, except for a higher bleeding in white patients (2% versus 0%, P = .04). There were no mortality or morbidity differences between racial and ethnic cohorts.ConclusionMorbidity and mortality after robotic-assisted revisional MBS do not seem to be mediated by race or ethnicity.     

Racial/ethnicity differences in endorsing influential factors for prostate cancer treatment choice: An analysis of data from the personal patient profile-prostate (P3P) I and II trials

ObjectiveRates and choice of treatment for localized prostate cancer vary according to race/ethnicity in American men. We hypothesized that there were group differences in influential values and preferences related to treatment decisions.MethodsWe analyzed samples from 2 multicenter, randomized trials of the Patient Profile-Prostate (P3P) I and II decision aid, first comparing the groups on other demographic and decisional variables using Chi-square tests. Stratified (P3P I vs. II) logistic regression was then used to assess the univariate association between race/ethnicity and endorsement of moderate-or-strong influence of 14 lifestyle factors, current or future symptoms, or important others on the decision. A multivariable stratified logistic regression with backward variable selection was used to further estimate the association between influential factors and race/ethnicity.ResultsThere were 494 and 392 participants in P3P I and P3P II, respectively, with 40 Hispanic, 168 non-Hispanic black, 637 non-Hispanic white, 19 others and 6 missing. Age (P = 0.0001), education (P < 0.0001), marital status (P < 0.0001), income (P < 0.0001), Internet use for information (P < 0.0001) and decisional control preference were significantly different across racial/ethnic groups. In adjusted analyses, we saw racial/ethnic differences in the decisional influence of age (Non-Hispanic Black (NHB) vs. Non-Hispanic White (NHW) OR: 0.56 95%CI 0.38–0.85 P = 0.002), religion/spirituality (NHB vs. NHW OR: 3.2095%CI1.95–5.26, P < 0.0001), future bladder function (NHB vs. NHW OR: 0.5795%CI 0.35–0.90, P = 0.04), future ability to engage in recreation (NHB vs. NHW OR: 0.5495%CI 0.34–0.86, P = 0.02), and a story of a famous person with prostate cancer (NHB vs. NHW OR: 2,11 95%CI 1.30–3.43, P = 0.007). No interactions were found.ConclusionOur results suggest racial/ethnic differences for influences underlying treatment choice. Better understanding these influences may help us present salient information about treatment options to patients and address disparities.     

African American men with low-grade prostate cancer have increased disease recurrence after prostatectomy compared with Caucasian men

PurposeTo explore whether disparities in outcomes exist between African American (AA) and Caucasian (CS) men with low-grade prostate cancer and similar cancer of the prostate risk assessment—postsurgery (CAPRA-S) features following prostatectomy (RP).MethodsThe overall cohort consisted of 1,265 men (234 AA and 1,031 CS) who met the National comprehensive cancer network criteria for low- to intermediate-risk prostate cancer and underwent RP between 1990 and 2012. We first evaluated whether clinical factors were associated with adverse pathologic outcomes and freedom from biochemical failure (FFbF) using the entire cohort. Next, we studied a subset of 705 men (112 AA and 593 CS) who had pathologic Gleason score≤6 (low-grade disease). Using this cohort, we determined whether race affected FFbF in men with RP-proven low-grade disease and similar CAPRA-S scores.ResultsWith a median follow-up time of 27 months, the overall 7-year FFbF rate was 86% vs. 79% in CS and AA men, respectively (P = 0.035). There was no significant difference in one or more adverse pathologic features between CS vs. AA men (27% vs. 31%; P = 0.35) or CAPRA-S score (P = 0.28). In the subset analysis of patients with low-grade disease, AA race was associated with worse FFbF outcomes (P = 0.002). Furthermore, AA race was a significant predictor of FFbF in men with low-grade disease (hazard ratio = 2.01, 95% CI: 1.08–3.72; P = 0.029).ConclusionsAA race is a predictor of worse FFbF outcomes in men with low-grade disease after RP. These results suggest that a subset of AA men with low-grade disease may benefit from more aggressive treatment.     

Socioeconomic status,race, and long-term outcomes after radical prostatectomy in an equal access health system: Results from the SEARCH database

Introduction

We previously found racial differences in biochemical recurrence (BCR) after radical prostatectomy (RP) persisted after adjusting for socioeconomic status (SES) while SES did not predict BCR. The impact on long-term prostate cancer (PC) outcomes is unclear. We hypothesized higher SES would associate with better long-term outcomes regardless of race.

Examining the association of health literacy and numeracy with prostate-related knowledge and prostate cancer treatment regret

IntroductionEducational materials used in prostate cancer shared decision-making are often written above the health literacy levels of the patients that may benefit the most from such tools. Poor understanding the oncologic and functional outcomes of prostate cancer treatment may influence patient regret during this process. In this study, we assess the association between health literacy, numeracy, prostate-related knowledge and treatment regret in a diverse population.Materials and MethodsPatients obtaining care between June and August of 2016 at both community-based and academic tertiary care facilities were assessed for health literacy and numeracy using validated instruments. Prostate knowledge was tested in those patients without a history of prostate cancer using a 29-item questionnaire and patient-level predictors of knowledge were assessed. Prostate cancer treatment regret was assessed in those patients who had a history of prostate cancer.ResultsA total of 90 patients were enrolled, 38 (42%) of whom had a history of prostate cancer. African American race (I = 0.039), financial strain (P < 0.001), and educational attainment (P < 0.001) were all associated with lower health literacy on multivariable analysis. Possessing a professional degree (P = 0.021) and higher health literacy (P = 0.001) were associated with greater prostate-related knowledge. Of those with a history of prostate cancer, 9 (24%) expressed treatment regret. Patients with regret were more likely to be African American (n = 6, 66.7% vs. 5, 17.2%, P = 0.004), not married (P = 0.016), and score lower on the literacy (1.0 vs. 8.0, P = 0.009) and numeracy (10.0 vs. 16.0, P = 0.016) scales.ConclusionsWe identified lower health literacy among African American men, and lower prostate-related knowledge in those with poor health literacy. To our knowledge, this is the first study to show an association between health literacy and prostate cancer treatment regret.     

Candidacy for active surveillance may be associated with improved functional outcomes after prostatectomy

ObjectiveIn an effort to curb overtreatment, active surveillance (AS) has grown in popularity as an option for men with low-risk prostate cancer. We evaluated the histopathologic and functional outcomes of patients who qualified for AS, but opted for robotic-assisted laparoscopic prostatectomy (RALP), and compared them to non-AS candidates.MethodsAn institutional database of 1,477 RALP performed by a single surgeon was queried for AS candidates, defined as PSA <10 ng/mL, biopsy Gleason score ≤6 with a minimum of 10 biopsy cores, <3 positive cores with <50% tumor volume in a single core and clinical stage ≤T2a.ResultsOf the 352 patients who would have qualified for AS, 159 (45%) were upgraded: 143 (41%) to Gl 3 + 4, 16 (4.5%) to 4 + 3, zero to Gleason 8 or higher. Seventeen (4.8%) patients were upstaged to pT3. AS candidates were younger and had more favorable tumor characteristics, but similar preoperative functional status. Bilateral nerve sparing was performed on 96% of AS candidates vs. 86% of non-AS candidates (P < 0.001). After 12 months of follow-up in patients who received bilateral nerve sparing, continence was higher in the AS cohort (98% vs. 92%, P < 0.001) but potency was equivalent (87% in each, P = 0.89). On multivariable analysis, candidacy for AS was independently associated with improved continence, but not potency.ConclusionsIn addition to having the expected favorable histopathologic features, AS candidates who desire definitive therapy have a high likelihood of achieving excellent functional outcomes, perhaps superior to non-AS candidates, following RALP.     

Radical prostatectomy findings and oncologic outcomes in patients with prostate cancer detected on systematic sextant biopsy only,MRI-targeted biopsy only,or both

ObjectiveMagnetic resonance imaging-targeted biopsy (T-Bx) has been shown to more accurately detect clinically significant prostate cancer. However, the clinical significance of cancer detection on T-Bx, followed by definitive treatment, needs to be further investigated. We herein investigated unique cohorts of patients with prostate cancer detected on systematic sextant biopsy (S-Bx) and/or T-Bx.Materials and methodsWe assessed consecutive patients who had undergone T-Bx with concurrent S-Bx (6 sites, ≥12 cores), followed by radical prostatectomy from 2015 to 2019. Within our Surgical Pathology database, we identified a total of 222 men who met the inclusion criteria for prostatic adenocarcinoma on either S-Bx or T-Bx, or both (B-Bx). Radical prostatectomy findings and oncologic outcomes were then compared among groups.ResultsProstate cancer was detected on S-Bx only (n = 32; 14%), T-Bx only (n = 40; 18%), or B-Bx (n = 150; 68%). Compared to cases with cancer detected on S-Bx only, those on T-Bx only or B-Bx showed significantly higher tumor grade (highest Grade Group in each patient) on biopsy and significantly larger estimated tumor volume on prostatectomy. There were no significant differences in tumor volume on biopsy, tumor grade on prostatectomy (except S-Bx vs. B-Bx), pT or pN stage category, surgical margin status, or preoperative prostate-specific antigen level between cases where cancer was detected on S-Bx only vs. T-Bx only or B-Bx. There were also no significant differences in any of these clinicopathologic features between cancers detected on T-Bx only vs. B-Bx. Kaplan-Meier analysis revealed a significantly higher risk of biochemical recurrence after prostatectomy in patients whose cancer was detected on T-Bx only (P = 0.020) or B-Bx (P = 0.032) than in those on S-Bx only. No significant difference in recurrence-free survival between T-Bx only vs. B-Bx cases (P = 0.601) was seen. In multivariate analysis, cancer detection on T-Bx only (vs. S-Bx only) showed significance for recurrence (hazard ratio = 8.482, P = 0.045).ConclusionsDetection of prostate cancer on T-Bx, in addition to or instead of S-Bx, was found to be associated with larger tumor volume as well as worse prognosis. However, no significant clinicopathologic impact of simultaneous tumor detection on S-Bx was indicated in patients with prostate cancer present on T-Bx.     

Urinary nerve growth factor as an oncologic biomarker for prostate cancer aggressiveness

ObjectivesWe investigated urinary nerve growth factor (NGF) as a novel urinary biomarker for high-grade prostate cancer (PCa).Methods and materialsAfter institutional review board approval for a prospective pilot study, we enrolled men at the preoperative visit before robotic-assisted radical prostatectomy. Demographics, urinary flow parameters, and urine samples were collected. Urinary NGF and urinary creatinine were obtained in the translational science laboratory. Pathologic and postoperative demographics were collected after surgery. NGF is the primary outcome variable (dependent variable). The pathologic Gleason score (ordinal variable≤6, 7, and ≤8) served as an independent grouping variable. Multivariate analysis using a general linear model was conducted to investigate associations between independent variables and NGF (dependent variable) after adjusting for urinary concentration and volume.ResultsWe enrolled and analyzed urine samples and pathologic data from 115 subjects. Patient pathology included 24% (n = 28) Gleason score 6 or less, 68% (n = 78) Gleason score 7, and 8% (n = 9) Gleason score 8 or greater. Perineural invasion was more prevalent in higher-grade disease (P<0.001). The median NGF level was 24.1 pg/ml (range: 0.16–270.5 pg/ml) and was transformed to the log base 10 scale. Total bladder volume, urinary creatinine level, prostate-specific antigen level, and diabetes were correlated with the Log NGF. In a general linear model, adjusting for bladder volume and urinary creatinine, increasing Log₁₀ NGF was associated with higher Gleason score (Gleason category≤6, 7, and≥8; P = 0.003).ConclusionsUrinary NGF may be a biomarker for higher-grade PCa. Our pilot study suggests further investigation is warranted to determine whether urinary NGF could provide unique additional information in patients with PCa.     

Validating the total cancer location density metric for stratifying patients with low-risk localized prostate cancer at higher risk of grade group reclassification while on active surveillance

PurposeTo validate a previously proposed prognostic metric, Total Cancer Location (TCLo) density, in a contemporary cohort of men with grade group (GG) 1 prostate cancer (PCa) on active surveillance (AS).MethodsWe evaluated 123 patients who entered AS with maximum GG1 PCa at diagnostic and/or confirmatory biopsy. TCLo was defined as the total number of PCa locations identified on both biopsy sessions. TCLo density was calculated as TCLo / prostate volume [ml]. Primary endpoint was progression-free survival (PFS), defined as time from confirmatory biopsy to grade group reclassification (GGR) on repeat biopsy or prostatectomy. Optimal cut-point for TCLo density was predefined in a previously reported cohort and applied to this contemporary cohort. Kaplan-Meier and multivariable Cox regression analysis were used to estimate the association of predictors with PFS.ResultsDuring median follow-up of 7.8 years, (IQR 7.3–8.2) 34 men had GGR. Using previously defined cut-points, PFS at 5-years was 60% (95% CI: 44%–81%) vs. 89% (95% CI: 83%–96%) in men with high (≥0.06 ml^?1) vs. low (<0.06 ml^?1) TCLo density, and 63% (95% CI: 48%–82%) vs. 90% (95% CI: 83%–96%) in men with high (≥3) vs. low (≤2) TCLo (log-rank test: P < 0.0001, respectively). Adjusting for age, prostate volume, percent of positive cores and PSA, both higher TCLo density (HR [per 0.01 ml^?1 increase]: 1.18, 95% CI: 1.05–1.33, P = 0.005) and TCLo (HR: 1.69, 95% CI: 1.20–2.38, P = 0.002) were associated with shorter PFS.ConclusionThe previously suggested prognostic value of TCLo density was confirmed in this validation cohort. TCLo alone performed similarly well. Patients with high TCLo density (≥0.06 ml^?1) or TCLo (>2) were at greater risk of GGR while on AS. With external validation, these metric may help guide risk-adapted surveillance protocols.     

Biopsy accuracy in identifying unilateral prostate cancer depends on prostate weight

ObjectiveTo evaluate the association between prostate weight and the diagnostic performance of routine biopsy schemes in detecting unilateral prostate cancer (PCa) that may be amenable to focal therapy.Methods and MaterialsRetrospective analysis of patients undergoing radical prostatectomy at Duke University Medical Center from 1990 to 2007. The cohort was dichotomized according to prostate weight (≤40 and >40 g) and further divided by biopsy scheme: 6–9 (sextant) and 10–20 cores (extended). Diagnostic accuracy, sensitivity, specificity, and positive and negative predictive values were calculated within each prostate weight group and compared between biopsy schemes.ResultsA total of 859 patients were included in the study. Patients with prostates >40 g were generally older and had higher PSA levels (P < 0.0001 and P = 0.036, respectively). Unilateral disease was more common in prostates >40 g both on biopsy (69% vs. 60%, P = 0.009) and on final pathology (21% vs. 14%, P = 0.017) despite larger total tumor volume (6.1 vs. 4.8 cc, P < 0.001). Low grade PCa was also more common in larger glands (P = 0.003). Overall, extended biopsy schemes performed better than sextant but the benefit was statistically significant only in prostates >40 g.ConclusionsDespite having higher tumor volumes, men with prostate weight >40 g were more likely to have unilateral PCa than those with smaller prostates. In prostates >40 g, increasing the number of cores harvested at biopsy increased the diagnostic performance for detecting cancer laterality. Therefore, our results suggest that the benefit of more extensive tissue sampling may be higher in larger prostates compared with smaller ones when selecting candidates for prostate hemiablation.     

Impact of systemic Immune–inflammation Index on oncologic outcomes in patients treated with radical prostatectomy for clinically nonmetastatic prostate cancer

PurposeTo evaluate the predictive and prognostic value of the Systemic Immune–inflammation Index (SII) in a large cohort of patients treated with radical prostatectomy (RP) for clinically non–metastatic prostate cancer (PCa).MethodsWe retrospectively analyzed our multicenter database comprising 6,039 consecutive patients. The optimal preoperative SII cut–off value was assessed with the Youden index calculated on a time–dependent receiver operating characteristic (ROC) curve. Logistic regression and Cox regression analyses were used to investigate the association of SII with pathologic features and biochemical recurrence (BCR), respectively. The discriminatory ability of the models was evaluated by calculating the concordance-indices (C-Index). The clinical benefit of the implementation of SII in clinical decision making was assessed using decision curve analysis (DCA).ResultsPatients with high preoperative SII (≥ 620) were more likely to have adverse clinicopathologic features. On multivariable logistic regression analysis, high preoperative SII was independently associated with extracapsular extension (odds ratio [OR] 1.16, P = 0.041), non–organ confined disease (OR 1.18, P = 0.022), and upgrading at RP (OR 1.23, P < 0.001). We built two Cox regression models including preoperative and postoperative variables. In the preoperative multivariable model, high preoperative SII was associated with BCR (hazard ratio [HR] 1.34, 95% CI 1.15-1.55, P < 0.001). In the postoperative multivariable model, SII was not associated with BCR (P = 0.078). The addition of SII to established models did not improve their discriminatory ability nor did it increase the clinical net benefit on DCA.ConclusionIn men treated with RP for clinically nonmetastatic PCa, high preoperative SII was statistically associated with an increased risk of adverse pathologic features at RP as well as BCR. However, it did not improve the predictive accuracy and clinical value beyond that obtained by current predictive and prognostic models. SII together with a panel of complementary biomarkers is praised to help guide decision–making in clinically nonmetastatic PCa.     

How does a prebiopsy mri approach for prostate cancer diagnosis affect prostatectomy upgrade rates?

BackgroundTo compare the pathologic upgrade and downgrade rates after radical prostatectomy (RP) between patients diagnosed by prebiopsy prostate MRI followed by a combination of systematic and fusion biopsy (ComBx) versus patients undergoing systematic biopsy only (SBx).MethodsA retrospective review of men undergoing RP at our institution between Jan 2014 and Mar 2020 was performed. These patients were separated into two independent cohorts based on two approaches: Patients receiving prebiopsy prostate MRI during initial evaluation and those who did not receive MRI. Patients with positive MRI findings underwent subsequent ComBx to confirm diagnosis while those without MRI underwent standard trans-rectal ultrasound (TRUS) guided systematic 12-core biopsy (SBx). Primary outcomes were rates of pathological upgrade (prostatectomy grade higher than grade determined at time of biopsy) and downgrade (prostatectomy grade lower than biopsy grade).ResultsA total of 213 patients undergoing radical prostatectomy, 91 diagnosed via a prebiopsy MRI and ComBx approach and 122 diagnosed by a traditional SBx approach, were included in the study. There was no significant difference between age, PSA, or positive family history between the two cohorts. Of the 91 patients who received prebiopsy MRI, 88 patients were determined to have a PIRADS 4 or 5 lesion. Patients who received MRI and subsequent ComBx had a lower rate of any pathological upgrade after RP (9.89% vs. 22.13%, P = 0.018) without a significant difference in pathologic downgrade rate (28.57% vs. 18.85%, P = 0.095). On multivariable logistic regression, receiving prebiopsy MRI during initial evaluation was the single negative independent predictor of pathologic upgrade (OR = 0.23, P = 0.017). A prebiopsy MRI approach was also the single predictor of pathologic downgrade (OR = 3.13, P = 0.041).ConclusionsPatients receiving prebiopsy MRI during prostate cancer evaluation were less likely to have their PCa upgraded. Furthermore, although diagnosis via MRI and subsequent ComBx was associated with an increased rate of downgrades after RP, relatively few resulted in a downgrade from clinically significant to clinically insignificant cancer.     

The rising incidence of ductal adenocarcinoma and intraductal carcinoma of the prostate: Diagnostic accuracy of biopsy,MRI-visibility,and outcomes

IntroductionDuctal adenocarcinoma (DA) and intraductal carcinoma (IDC) of the prostate are associated with higher stage disease at radical prostatectomy (RP). We evaluated diagnostic accuracy of biopsy, MRI-visibility, and outcomes for patients undergoing RP with DA/IDC histology compared to pure acinar adenocarcinoma (AA) of the prostate.Materials and MethodsA retrospective cohort study of men receiving RP between 2014 and 2021 revealing AA, DA, or IDC on final pathology was conducted. Multivariable logistic regression and Cox proportional hazards regression models were employed.ResultsA total of 609 patients were included with 103 found to have DA/IDC. Patients with DA/IDC were older and had higher PSA, biopsy grade group (GG), RP GG, and other pathologic findings (extraprostatic extension, lymphovascular invasion, perineural invasion, pN stage) compared to AA patients (all P < 0.05). On multivariable analysis, higher age, RP GG, and pT3a were associated with DA/IDC on RP (all P < 0.05). Sensitivity and specificity of biopsy compared to RP for diagnosis of DA/IDC was 29.1% (16.7% DA, 27.8% IDC) and 96.6% (99.3% DA, 96.6% IDC), respectively. In a subset of 281 men receiving MRI, PI-RADS distribution was similar for patients with DA/IDC vs. AA (90.7% vs. 80.7% with PI-RADS 4–5 lesions, P = 0.23) with slightly higher biopsy sensitivity (41.9%). DA/IDC was associated with worse BCR (HR = 1.77, P = 0.02) but not biopsy DA/IDC (P = 0.90).ConclusionsSensitivity of prostate biopsy was low for detection of DA/IDC histology at RP. Patients with DA/IDC histology had unfavorable pathologic features at RP and worse BCR. Of patients with DA/IDC at RP, 90.7% were categorized as PI-RADS 4 to 5 on preoperative MRI.     

Outcomes in racial minorities after robotic Roux-en-Y gastric bypass and sleeve gastrectomy: a retrospective review of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database

BackgroundThe rate of robotic-assisted metabolic and bariatric surgery (MBS) is increasing. While discord remains about racial disparity in primary MBS, there are no data on robotic MBS outcomes in racial cohorts.ObjectivesTo determine whether outcomes following robotic-assisted Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are mediated by race or ethnicity.SettingUniversity Hospital, United States.MethodsRobotic RYGB and SG cases were identified from the 2015–2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) databases using Current Procedure Terminology codes 43644, 43645, and 43775. Selected cases were stratified by race and ethnicity. Case-control matched and logistic regression analyses were performed.ResultsMatched analyses compared outcomes in 2666 RYGB cases of Black versus White patients and 1794 RYGB cases of Hispanic versus White patients. Black RYGB patients had longer operative lengths (OLs; P = .0008) and postoperative lengths of stay (P = .001), and a higher rate of pulmonary embolism (P = .05). Hispanic (versus White) RYGB patients had longer lengths of stay (P = .007). All other outcomes were similar between RYGB racial and ethnic cohorts. Matched analyses also compared outcomes of 8328 SG cases in Black versus White patients and 4852 SG cases in Hispanic versus White patients. Black patients had longer OLs (P = .004), had longer lengths of stay (P < .0001), had higher overall morbidity (P = .02), had higher bariatric-related morbidity (P = .02), had higher rates of readmission (P = .009), and were more likely to have an operative drain present at 30 days (P = .001). All other outcome measures were similar between racial/ethnic SG cohorts.ConclusionRobotic-assisted SG is associated with higher overall and bariatric-related morbidity, but not mortality. However, robotic-assisted RYGB and SG remain safe, with lower rates of mortality and morbidity.     

Magnetic resonance imaging–targeted vs. conventional transrectal ultrasound–guided prostate biopsy: Single-institution,matched cohort comparison

ObjectivesTo compare magnetic resonance imaging–targeted biopsy (MRITB) and conventional transrectal ultrasound–guided biopsy (TRUSGB) in the detection of prostate cancer (PCa) at our institution.MethodsOur prospective registry of patients undergoing prostate MRITB from December 2010 to July 2013 was analyzed. Patients were matched one-to-one to patients who underwent TRUSGB based on the following characteristics: age, prostate-specific antigen level, prostate volume, race, family history of PCa, initial digital rectal examination (DRE), prior use of 5-alpha reductase inhibitor, and prior diagnosis of PCa. MRITB was performed using a TargetScan system with the patient under general anesthesia. Magnetic resonance imaging suspicious regions (MSRs) were targeted with cognitive registration, and a full TargetScan template biopsy (TSTB) was also performed.ResultsIn total, 34 MRITB patients were matched individually to 34 TRUSGB patients. As compared with TRUSGB, patients who underwent MRITB had a greater overall rate of PCa detection (76% vs. 56%, P = 0.12) and a significantly higher number with Gleason score≥7 (41% vs. 15%, P = 0.03), whereas the rates of Gleason score 6 PCa detection were similar between MRITB and TRUSGB (35% vs. 41%, P = 0.80). As compared with the TSTB, magnetic resonance imaging suspicious regions–directed biopsies during MRITB had a significantly higher overall PCa detection (54% vs. 24%, P<0.01) and Gleason score≥7 PCa detection (25% vs. 8%, P<0.01). When compared with TSTB, TRUSGB had similar detection rates for benign prostate tissue (76% vs. 79%, P = 0.64), Gleason score 6 PCa (16% vs. 14%, P = 0.49), and Gleason score ≥7 PCa detection (8% vs. 7%, P = 1.0).ConclusionsCognitive registration MRITB significantly improves the detection of Gleason score≥7 PCa as compared with conventional TRUSGB.     

Clinicopathological,functional, and immediate oncologic outcome assessment in men aged≤50 years with prostate cancer after robotic prostatectomy

Background

To define the pathologic and functional outcomes of men 50 years of age and younger with prostate cancer in a contemporary robotic cohort, this study was designed.

Prognostic capabilities and clinical utility of cell cycle progression testing,prostate imaging reporting and data system,version 2, and clinicopathologic data in management of localized prostate cancer

ObjectivesTo compare the prognostic capabilities and clinical utility of the cell cycle progression (CCP) gene expression classifier test, multiparametric magnetic resonance imaging (mpMRI) with Prostate Imaging Reporting and Data System (PI-RADS) scoring, and clinicopathologic data in select prostate cancer (PCa) medical management scenarios.Patients and methodsRetrospective, observational analysis of patients (N = 222) ascertained sequentially from a single urology practice from January 2015 to June 2018. Men were included if they had localized PCa, a CCP score, and an mpMRI PI-RADS v2 score. Cohort 1 (n = 156): men with newly diagnosed PCa, with or without a previous negative biopsy. Cohort 2 (n = 66): men who initiated active surveillance (AS) without CCP testing, but who received the test during AS. CCP was combined with the UCSF Cancer of the Prostate Risk Assessment (CAPRA) score to produce a clinical cell-cycle risk (CCR) score, which was reported in the context of a validated AS threshold. Spearman's rank correlation test was used to evaluate correlations between variables. Generalized linear models were used to predict binary Gleason score category and medical management selection (AS or curative therapy). Likelihood-ratio tests were used to determine predictor significance in both univariable and multivariable models.ResultsIn the combined cohorts, modest but significant correlations were observed between PI-RADS score and CCP (r_s = 0.22, P = 8.1 × 10^?4), CAPRA (r_s= 0.36, P = 4.8 × 10^?8), or CCR (r_s = 0.37, P = 2.0 × 10^?8), suggesting that much of the prognostic information captured by these measures is independent. When accounting for CAPRA and PI-RADS score, CCP was a significant predictor of higher-grade tumor after radical prostatectomy, with the resected tumor approximately 4 times more likely to harbor Gleason ≥4+3 per 1-unit increase in CCP in Cohort 1 (Odds Ratio [OR], 4.10 [95% confidence interval [CI], 1.46, 14.12], P = 0.006) and in the combined cohorts (OR, 3.72 [95% CI, 1.39, 11.88], P = 0.008). On multivariable analysis, PI-RADS score was not a significant predictor of post-radical prostatectomy Gleason score. Both CCP and CCR were significant and independent predictors of AS versus curative therapy in Cohort 1 on multivariable analysis, with each 1-unit increase in score corresponding to an approximately 2-fold greater likelihood of selecting curative therapy (CCP OR, 2.08 [95% CI, 1.16, 3.94], P = 0.014) (CCR OR, 2.33 [95% CI, 1.48, 3.87], P = 1.5 × 10^?4). CCR at or below the AS threshold significantly reduced the probability of selecting curative therapy over AS (OR, 0.28 [95% CI, 0.13, 0.57], P = 4.4 × 10^?4), further validating the clinical utility of the AS threshold.ConclusionCCP was a better predictor of both tumor grade and subsequent patient management than was PI-RADS. Even in the context of targeted biopsy, molecular information remains essential to ensure precise risk assessment for men with newly diagnosed PCa.