Technological developments enable measuring and using patient-reported outcomes data in orthopaedic clinical practice

Patient-reported outcomes measures form the backbone of outcomes evaluation in orthopaedics, with most of the literature now relying on these scoring tools to measure change in patient health status. This patient-reported information is increasingly collected routinely by orthopaedic providers but use of the data is typically restricted to academic research. Developments in electronic data capture and the outcome tools themselves now allow use of this data as part of the clinical consultation. This review evaluates the role of patient reported outcomes data as a tool to enhance daily orthopaedic clinical practice, and documents how develop-ments in electronic outcome measures, computer-adaptive questionnaire design and instant graphical display of questionnaire can facilitate enhanced patient-clinician shared decision making.     

Feasibility of minimally invasive lymphadenectomy in bladder and prostate cancer surgery

With the rapid and widespread adoption of minimally invasive procedures (laparoscopic and robotic) for the treatment of prostate and bladder cancers in the last decade, concerns have been raised regarding whether the technique can emulate the time-tested gold standard open procedures. This article briefly reviews the indications for lymph node dissection for bladder and prostate cancer, and reviews the role of extended lymphadenectomy in each procedure. Much of the focus of this review is on minimally invasive approaches and the technical aspects of the procedures, the feasibility of the robotic technique, and early oncologic outcomes.     

非肌层浸润性膀胱癌指南的依从性和临床实践的现状分析

目的了解国内泌尿外科医生对非肌层浸润性膀胱癌(NMIBC)相关指南的知晓、依从和实施现状,为规范NMIBC治疗和推动指南实施提供依据。方法选择2019年8月至2019年11月期间参加泌尿外科专科区域会议的泌尿外科医生发放问卷调查,并对结果进行描述分析。结果共收到171份有效问卷,调研对象平均年龄(42.63±7.79)岁,首次TURBT切除需要达到肌层和术后即刻单剂量膀胱灌注化疗的知晓率和依从率均较高(>90%),二次TURBT指征中首次切除不充分的知晓率较高(68.42%),但因该指征为患者推荐和患者选择的比例较低(14.71%,13.77%)。低危NMIBC患者不推荐膀胱灌注化疗和BCG免疫治疗的知晓率和依从率均较低,存在过度使用的问题。BCG治疗因医疗资源不足和经济因素在中高危患者使用不足。结论指南推荐和临床实践在5个关键临床问题上存在较大差异,需针对性的提出可行的实施策略,提高指南的依从性并充分发挥其临床价值。     

Sex differences in bladder cancer outcomes among smokers with advanced bladder cancer

Study Type – Aetiology (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Smoking is well described among the most important risk factors for bladder cancer. It is also known that higher quantity of tobacco exposure is associated with higher bladder cancer risk and that smoking cessation is known to be associated with lower risk of bladder cancer. Furthermore, among patients with non‐muscle invasive bladder cancer, smoking cessation decreases the risk of tumour recurrence. On the other hand, the effect of smoking on tumour stages at presentation and especially on prognosis is not well studied. The current study describes the presentation and outcome of 564 patients (64% smokers, 36% non‐smokers) treated with radical cystectomy. Patients with smoking history have more advanced outcome at the time of radical surgery and significantly worse outcome after surgery when compared to non‐smokers, although the effect of smoking was not significant when survival was studied in multivariable analysis including classic prognostic parameters such as tumour grade, stage and adjuvant chemotherapy. Finally, there was a surprising finding that history of smoking affected outcome among male patients but such effect was not noted among female patients.

OBJECTIVE

? To study the effect of smoking on bladder cancer presentation and outcome in a large cystectomy population.

PATIENTS AND METHODS

? A database including 546 patients from the University Health Network (Toronto, Canada) and Turku University Hospital (Turku, Finland) was studied. ? In addition to the association of smoking with clinicopathological parameters, the effect of smoking on survival was analyzed. ? Categorical data were analyzed by the chi‐squared test and numerical data were analyzed by Student's t‐test. ? The Kaplan–Meier method, log‐rank test and a proportional hazards model were used to estimate the effect of smoking on survival.

RESULTS

? In total, 352 patients (64%) were smokers and 194 (36%) were non‐smokers. ? Smokers had more frequently advanced tumours and nodal metastasis. ? The 10‐year disease‐specific survival (DSS) was 52% vs 66% for smokers and non‐smokers, respectively (P= 0.039). ? Smokers also had significantly worse overall survival (10‐year overall survival 37% vs 62%; P= 0.015). ? Smoking affected significant DSS among men (P= 0.012), although no effect was observed among women. ? In a univariate model smoking was associated with a hazard ratio (HR) of 1.4 (95% confidence interval, CI, 1.0–1.9) for bladder cancer specific mortality and 1.4 (95% CI, 1.1–1.8) for overall mortality. ? In a multivariate model, smoking did not impact on DSS (HR, 1.1; 95% CI, 0.8–1.6; P= 0.41). ? In addition to advanced stage and nodal metastasis, female sex was an independent risk factor for DSS (HR, 1.6; 95% CI, 1.1–2.3; P= 0.007).

CONCLUSIONS

? Smokers appear to have worse outcomes after radical cystectomy for bladder cancer; however, it does not appear to be an independent prognostic factor for survival. ? Smoking affected survival only among men. ? Women had poorer survival but smoking was not a contributing factor to this.     

Prospective validation of the Kaiser Permanente prostate cancer risk calculator in a contemporary,racially diverse,referral population

PurposeTo prospectively validate a new prostate cancer risk calculator in a racially diverse population.Materials and MethodsWe recently developed, internally validated and published the Kaiser Permanente Prostate Cancer Risk Calculator. This study is a prospective validation of the calculator in a separate, referral population over a 21-month period. All patients were tested with a uniform PSA assay and a standardized systematic, ultrasound-guided biopsy scheme. We report on 3 calculator models: Model 1 included age, race, PSA, prior biopsy status, body mass index, and family history of prostate cancer; Model 2 added digital rectal exam to Model 1 variables; Model 3 added prostate volume to Model 2 variables. We considered three outcomes: high-grade disease (Gleason score ≥7), low-grade disease (Gleason score=6), and no cancer. Predictive discrimination and calibration were calculated. How each model might alter biopsy frequency and outcomes at various thresholds of risk was assessed. We compared the performance of our calculator with two other calculators.ResultsIn 4178 patients (16.2% Asian, 11.3% African American, 13.5% Hispanic), cancer was found in 53%; 62% were Gleason score ≥7. Using a high-grade risk threshold for biopsy of ≥10%, Model 2 predictions would result in 9% of men avoiding a biopsy, while only missing 2% of high-grade cancers. At the same threshold, Model 3 predictions would result in 26% of men avoiding a biopsy, while only missing 5% of high-grade cancers. The c-statistics for Models 1, 2, and 3 to predict high-grade disease vs. low-grade or no cancer were 0.76, 0.79 and 0.85, respectively. The c-statistics for Models 1, 2, and 3 to predict any prostate cancer vs. no cancer were 0.70, 0.72 and 0.80, respectively. All models were well calibrated for all outcomes. Our Model 3 calculator had superior discrimination for high grade disease (c-statistic=0.85, 0.84-0.86) and any cancer (0.80, 0.79-0.82) compared to the PBCG calculator [(0.79, 0.78-0.80); 0.72 (0.70-0.73)] and the PCPT calculator [(0.75, 0.74-0.77); 0.69 (0.67-0.70)], respectively. In the high-grade cancer predicted risk range of 0-30%, our Model 2 was better calibrated than the PCPT and PBCG calculators.ConclusionsThis validation of our calculator showed excellent performance characteristics.     

Global developments in prostate cancer research and clinical practice

The prostate cancer foundation （PCF） is committed to the facilitation of globalknowledge exchange as a mechanism for more rapidly discovering and developing new medicines and treatments for prostate cancer （PCa） patients worldwide. For the past 3 years, PCF has partnered with the Chinese Prostate Cancer Consortium and Shanghai Changhai Hospital to host a conference in China that brings together basic, translational, and clinical researchers from China and abroad to form new partnerships and exchange findings, insights, perspectives, and ideas toward improving the treatment of PCa. The seventh forum of prostate disease held in Shanghai, China, on July 26-28, 2013, focused on current and emerging developments and approaches in PCa diagnosis, prognosis, and treatment, and the discovery and targeting of disease mechanisms that drive metastasis and lethal subtypes of castrate-resistant PCa （CRPC）.     

Frequencies of obesity susceptibility alleles among ethnically and racially diverse bariatric patient populations

BackgroundGenetic factors likely play a role in obesity and the outcomes after bariatric surgery. Single nucleotide polymorphisms in or near the insulin-induced gene 2 (INSIG-2), fat mass and obesity-associated gene (FTO), melanocortin 4 receptor gene (MC4R), and proprotein convertase subtilisn/kexin type 1 gene (PCSK-1) have been associated with class III obesity in whites. Minimal data are available regarding the genetic susceptibility to obesity in class III obese nonwhites, especially Hispanics. Our objective was to perform a comparative analysis of 4 common genetic variants (INSIG-2, FTO, MC4R, and PCSK-1) associated with obesity in a diverse population of bariatric surgery patients to determine whether a difference exists by ethnicity (white versus Hispanic). The setting of the study was 2 university hospitals in the United States.MethodsBariatric surgery patients from 2 different institutions were enrolled prospectively, and genotyping was performed. Differences in the distribution of INSIG-2, FTO, MC4R, and PCSK-1 single nucleotide polymorphisms among the different ethnicities (whites and Hispanics) were compared using an additive model (0, 1, or 2 risk alleles). A propensity-matched analysis was used to account for cohort differences.ResultsA total of 1276 bariatric patients were genotyped for the INSIG-2, FTO, MC4R, and PCSK-1 obesity single nucleotide polymorphisms. Statistically significant differences in FTO, INSIG-2, MC4R, and PCSK-1 were seen using an additive model. FTO, PCSK-1, and MC4R (test for trend) remained significantly different in the propensity analysis.ConclusionSignificant differences in the frequencies of several common obesity susceptibility variants in or near FTO, PCSK-1, and MC4R were found in white and Hispanic patients with class III obesity undergoing bariatric surgery. Larger studies in more class III obese Hispanics of different nationalities are needed.     

Survival outcomes in prostate cancer patients with a prior cancer

BackgroundTo shed light on the survival outcomes of prostate cancer (PCa) patients diagnosed after a prior cancer and identify prognostic factors for overall survival (OS) and cancer-specific survival (CSS) in PCa patients.MethodsIn the primary group, a total of 1,778 PCa patients with a prior cancer were identified in the Surveillance, Epidemiology, and End Results (SEER) database from 2005 to 2015, retrospectively. Baseline characteristics and causes of death (COD) of these patients were collected and compared. In the second group, a total of 10,296 PCa patients [5,148 patients with PCa as the only malignancy and 5,148 patients with PCa as their second primary malignancy (SPM)] diagnosed between 2010 and 2011 were extracted to investigate the impact of prior cancers on survival outcomes.ResultsIn PCa patients with a prior cancer, the most common type of prior cancer was from gastrointestinal system (29.92%), followed by urinary system (21.37%). Patients were more likely to die of the prior caner, and those with prior cancer from respiratory system had the worst survival outcomes. Moreover, the overall ratios in patients with stage (PCa) I–II and III–IV diseases were 0.21 and 1.65, indicating that patients with higher stage diseases were more likely to die of PCa. In the second group, patients with PCa as the SPM had worse OS than those with PCa as the first primary cancer. Lastly, prognostic factors for OS and CSS in PCa patients were explored.ConclusionsPCa remains to be an important COD for patients with a prior malignancy, especially for those with high-stage diseases. PCa patients with a prior cancer had worse survival outcomes than those without.     

Prospective development of a prostate cancer risk calculator in a racially diverse population: The Kaiser Permanente Prostate Cancer Risk Calculator

PurposeTo prospectively develop a prostate cancer (CaP) risk calculator in a racially diverse population.Materials and MethodsAll patients referred for prostate biopsy due to an elevated prostate-specific antigen or abnormal digital rectal exam in a 19-months period at Kaiser Permanente Northern California underwent a standardized systematic, ultrasound-guided biopsy scheme (14-cores for initial biopsy, 18–20 cores for repeat biopsy). All pertinent clinical variables were prospectively collected. The highest Gleason score for each patient was recorded for all positive biopsies. We used a split sample design to develop and validate 3 multivariable prediction models using multinomial logistic regression with the least absolute shrinkage and selection operator. All models included these core variables: age, race, prostate-specific antigen, prior biopsy status, body mass index, and family history of CaP. Model 1 included only the core variables, Model 2 added digital rectal exam, and Model 3 added digital rectal exam and prostate volume. We considered 3 outcomes: high-grade disease (Gleason score ≥7), low-grade disease (Gleason score = 6), and no cancer. Predictive discrimination was quantified using the c-statistic.ResultsComplete data were available for 2,967 patients. Cancer was found in 50% of patients: of these, 58% were Gleason score ≥7 and 42% were low grade. Compared to Caucasians, African Americans were at a higher risk while Asians and Hispanics were at a lower risk for overall and high-grade cancer detection. The number of prior negative biopsies was also protective for these outcomes. The c-statistics for Model 1, 2, and 3 to predict high-grade disease vs. low-grade or no cancer were 0.76, 0.79, and 0.85, respectively. The c-statistics for Model 1, 2, and 3 to predict any CaP vs. no cancer were 0.69, 0.70, and 0.79, respectively. All models were well calibrated for all outcomes.ConclusionsIn men with elevated PSA levels, our calculator provides useful information that may enhance the shared decision-making process regarding the need for biopsy.     

去势抵抗性前列腺癌治疗的循证实践

目的:以1例去势抵抗性前列腺癌(CRPC)患者的治疗为例,阐述循证实践的具体步骤和内容。方法:针对患者病情提出临床问题,系统检索Pub Med、EMBASE、Cochrane Library、Clinical Trial Registries等数据库,检索时限截至2014年12月,查找相关的研究证据,并对证据进行质量评价及应用。结果:患者病情得到缓解,治疗有效。结论:开展循证实践需要结合患者病情、研究证据和患者意愿,并遵循一定的步骤。     

Changes in weight,physical and psychosocial patient-reported outcomes among obese women receiving treatment for early-stage breast cancer: A nationwide clinical study

BackgroundEvidence on how weight loss correlates to health-related quality-of-life (HRQOL) among obese breast cancer (BC) patients is limited. We aimed to evaluate associations between weight changes and HRQOL.MethodsWe included 993 obese women with stage I-II-III BC from CANTO, a multicenter, prospective cohort collecting longitudinal, objectively-assessed anthropometric measures and HRQOL data (NCT01993498). Associations between weight changes (±5% between diagnosis and post-treatment [shortly after completion of surgery, adjuvant chemo- or radiation-therapy]) and patient-reported HRQOL (EORTC QLQ-C30/B23) were comprehensively evaluated. Changes in HRQOL and odds of severely impaired HRQOL were assessed using multivariable generalized estimating equations and logistic regression, respectively.Results14.1% women gained weight, 67.3% remained stable and 18.6% lost weight. Significant decreases in functional status and exacerbation of symptoms were observed overall post-treatment. Compared to gaining weight or remaining stable, obese women who lost weight experienced less of a decline in HRQOL, reporting better physical function (mean change [95%CI] for gain, stability and loss: −12.9 [-16.5,-9.3], −6.9 [-8.2,-5.5] and −6.2 [-8.7,-3.7]; p_{interaction[weight-change-by-time]} = 0.006), less dyspnea (+18.9 [+12.3,+25.6], +9.2 [+6.5,+11.9] and +3.2 [-1.0,+7.3]; p_interaction = 0.0003), and fewer breast symptoms (+22.1 [+16.8,+27.3], +18.0 [+15.7,+20.3] and +13.4 [+9.0,+17.2]; p_interaction = 0.044). Weight loss was also significantly associated with reduced odds of severe pain compared with weight gain (OR [95%CI] = 0.51 [0.31–0.86], p = 0.011) or stability (OR [95%CI] = 0.62 [0.41–0.95], p = 0.029). No associations between weight loss and worsening of other physical or psychosocial parameters were found.ConclusionsThis large contemporary study suggests that weight loss among obese BC patients during early survivorship was associated with better patient-reported outcomes, without evidence of worsened functionality or symptomatology in any domain of HRQOL.     

经尿道电切治疗晚期前列腺癌伴膀胱出口梗阻

目的 总结经尿道前列腺电切治疗晚期前列腺癌伴膀胱出口梗阻的手术经验.方法 本组36例患者,年龄68～89岁,平均76.5岁.术前IPSS评分为(18.3±3.1)分;总PSA分别为(60.1±35.4)ng/ml;最大尿流率为(9.4±2.8)ml/s.穿刺病理确诊为前列腺癌,Gleasn评分为(7.3±1.8)分.Whitmore临床分期C期10例,D期26例.36例患者行经尿道前列腺电切术同时行双睾丸切除术,术后加用(氟他胺250mgtid或者比卡鲁胺50mgqd),行全雄激素阻断.结果 36例均顺利完成手术,无围手术期死亡病例.6例(16.7%)术后出现尿失禁,经保守治疗后治愈.1例术后大出血,二次手术止血后恢复顺利,1例术后4个月再次出现排尿困难,再次行TURP后,患者排尿通畅.随访24～55个月,死亡13例,其中死于前列腺癌10例,平均生存32个月,死于其他疾病3例.术后患者排尿症状明显改善,术后3个月尿流率(17.5±3.5)ml/s,术后IPSS评分(8.1±3.4)分.结论 经尿道前列腺电切是治疗晚期前列腺癌伴膀胱出口梗阻的有效方法,可以快速改善患者的排尿症状,提高尿流率.