Anobel Y. Odisho

Geographic distribution of urologists throughout the United States using a county level approach.

PURPOSE The adequacy of the urologist work force in absolute numbers and relative distribution is unclear. To develop effective policies addressing the needs of an aging population we must better understand the urologist work force. We assessed the geographic distribution of urologists throughout the United States at the county level and determined the county characteristics associated with increased urologist density. MATERIALS AND METHODS County level data from the Department of Health and Human Services Area Resource File and the United States Census were analyzed in this ecological study. Logistic regression and ordinal logistic regression models were built to identify predictors of urologist density, defined as the number of urologists per 100,000 individuals. National patterns of urologist density were mapped graphically at the county level. RESULTS Overall 63% of the counties in the United States lack a urologist. Based on multivariate models urologists were less likely to be found in nonmetropolitan counties (OR 0.57, 95% CI 0.46-0.72) and rural counties (OR 0.03, 95% CI 0.02-0.06) than in metropolitan counties, which confirmed visually mapped models. Patterns of urologist density also appeared to be influenced by climate and county education levels rather than by traditional socioeconomic measures. Urologists younger than 45 years old were 3 times less likely to be located in nonmetropolitan and rural counties than their older counterparts. CONCLUSIONS The uneven distribution of urologists throughout the United States is likely to worsen as younger physicians continue to cluster in urban areas. Governing bodies must consider this distribution in their calls for increasing the number of training positions.

Urologist Density and County-Level Urologic Cancer Mortality

PURPOSE The surgical work force distribution at the county level varies widely across the United States, and the impact of differential access on cancer outcomes is unclear. We used urologists as a test case because they are the first care providers for urologic cancers, can easily be identified from available data sources, and are unevenly distributed throughout the country. The goal of this study was to determine the effect of increasing urologist density on local prostate, bladder, and kidney cancer mortality. PATIENTS AND METHODS Using county-level data from the Area Resource File, US Census, National Cancer Institute, and Centers for Disease Control, regression models were built for prostate, bladder, and kidney cancer mortality, controlling for categorized urologist density, county demographics, socioeconomic factors, and preexisting health care infrastructure. RESULTS For each of the three cancers, there was a statistically significant cancer-specific mortality reduction associated with counties that had more than zero urologists (16% to 22% reduction for prostate cancer, 17% to 20% reduction for bladder cancer, and 8% to 14% reduction for kidney cancer with increasing urologist density) relative to zero urologists. However, increasing density greater than two urologists per 100,000 people had no statistically significant impact on mortality for any of the tumors studied. CONCLUSION The presence of a urologist is associated with lower mortality for urologic cancers in that county, but increasing urologist density does not yield further improvements. Therefore, a nuanced and geographically aware policy toward the size and distribution of the future work force is most likely to provide the greatest population-level improvement in cancer mortality outcomes.

Outcomes for Radical Prostatectomy: Is It the Singer, the Song, or Both?

VOLUME NUMBER FEBRUARY J OURNAL OF C LINICAL O NCOLOGY COMMENTS AND CONTROVERSIES Outcomes for Radical Prostatectomy: Is It the Singer, the Song, or Both? Matthew R. Cooperberg, Anobel Y. Odisho, and Peter R. Carroll, University of California, San Francisco Helen Diller Comprehensive Cancer Center, San Francisco, CA See accompanying article on page 513 Radical prostatectomy is one of the many treatment options available to men with clinically localized prostate cancer, and it may be the preferred option for some on the basis of cancer risk and patient age, comorbidity, and preferences. 1 The procedure is associated with excellent cancer control rates. Overall prostate cancer–specific sur- vival at 15 years after prostatectomy has been shown to be approxi- mately 93%; even for those with advanced stage (T3, N⫹) and/or high-grade disease (Gleason grade 8-10), that figure is 63% to 74%. 2 Radical prostatectomy is the most highly used treatment for prostate cancer, with approximately 40% to 50% of men selecting this treat- ment initially. 3 The procedure can be performed by using various approaches, including retropubic, perineal and laparoscopic ap- proaches. Laparoscopic prostatectomy can be facilitated by using ro- bot assistance. Until recently, the vast majority of prostatectomies were performed using the open, retropubic approach, whereas the past decade has witnessed a rapid uptake of robot-assisted radical prostatectomy (RARP) nationwide. The robot is impressive technology, allowing the surgeon to sit at a console and direct a camera and two or three laparoscopic arms with six degrees of wristed motion for cutting, retracting, cauterizing, or suturing—all with high magnification and three-dimensional visual- ization. However, technology that is rapidly adopted should have clear benefits—increased effectiveness, less morbidity, more accessibility, and/or decreased cost. Many argue that the increased use of robotic technology may not be primarily driven by such benefits but rather by heavy marketing, whether by the company that produces the technol- ogy, by hospitals that have acquired it (at high cost), or by physicians who promote it to gain market share. Hospitals that acquire a robot appear to have the largest increases in surgical volume. 4,5 Indeed, a review of hospital Web sites demonstrates a mix of manufacturer and hospital claims of superior outcomes for robot-assisted surgery, with- out disclaimers regarding the limitations of existing outcomes data. 6 The problem of potentially misleading marketing is by no means unique to robot-assisted surgery; similar marginally founded claims are frequently made about other treatments as well. Although the number of prostatectomies performed has in- creased, the location and costs of installed robotic systems has central- ized care. Whereas outcomes may be improved, centralization leads to decreased access resulting from longer travel times, which dispropor- tionately affect patients with limited financial means. 7 RARP also tends to be more costly; on average, robotic surgery adds approx-

Nationally representative trends and geographic variation in treatment of localized prostate cancer: the Urologic Diseases in America project

Background:Several treatment options for clinically localized prostate cancer currently exist under the established guidelines. We aim to assess nationally representative trends in treatment over time and determine potential geographic variation using two large national claims registries.Methods:Men with prostate cancer insured by Medicare (1998–2006) or a private insurer (Ingenix database, 2002–2006) were identified using International Classification of Diseases-9 and Current Procedural Terminology-4 codes. Geographic variation and trends in the type of treatment utilized over time were assessed. Geographic data were mapped using the GeoCommons online mapping platform. Predictors of any treatment were determined using a hierarchical generalized linear mixed model using the logit link function.Results:The use of radical prostatectomy increased, 33–48%, in the privately insured i3 database while remaining stable at 12% in the Medicare population. There was a rapid uptake in the use of newer technologies over time in both the Medicare and i3 cohorts. The use of laparoscopic-assisted prostatectomy increased from 1% in 2002 to 41% in 2006 in i3 patients, whereas the incidence increased from 3% in 2002 to 35% in 2006 for Medicare patients. The use of neoadjuvant/adjuvant androgen deprivation therapy was lower in the i3 cohort and has decreased over time in both i3 and Medicare. Physician density had an impact on the type of primary treatment received in the New England region; however, this trend was not seen in the western or southern regions of the United States.Conclusions:Using two large national claims registries, we have demonstrated trends over time and substantial geographic variation in the type of primary treatment used for localized prostate cancer. Specifically, there has been a large increase in the use of newer technologies (that is, laparoscopic-assisted prostatectomy and intensity-modulated radiation therapy). These results elucidate the need for improved data collection on prostate cancer treatment outcomes to reduce unwarranted variation in care.

Reflex ImmunoCyt testing for the diagnosis of bladder cancer in patients with atypical urine cytology

BACKGROUND ImmunoCyt/uCyt (Scimedx, Denville, NJ, USA) is a well-established urinary marker assay with high sensitivity for the diagnosis of urothelial carcinoma (UC) and can function as a second-level test to arbitrate atypical reads of urine cytology. OBJECTIVE To determine the utility of uCyt as a reflex test for atypical cytology in patients undergoing a hematuria evaluation or surveillance with a history of UC. DESIGN, SETTING, AND PARTICIPANTS The uCyt assay was performed as a second-level reflex test on all voided urine cytology tests read as atypical between January 2007 and June 2010 in an academic medical center. Records were retrospectively reviewed. Three hundred twenty-four patients underwent a total of 506 uCyt assays. INTERVENTION Reflex uCyt assay on atypical urine cytology. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The uCyt test characteristics include sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). RESULTS AND LIMITATIONS Reflex uCyt was performed on 506 atypical voided urine samples that were followed by cystoscopy within 90 d. Reflex uCyt with a history of UC showed a sensitivity of 73%, a specificity of 49%, and an NPV of 80%. In those with a history of low-grade UC, reflex uCyt had a sensitivity of 75%, a specificity of 50%, and an NPV of 82%, while in those with a history of high-grade UC, it had a sensitivity of 74%, a specificity of 44%, and an NPV of 79%. Without prior history of UC, reflex uCyt had a sensitivity of 85%, a specificity of 59%, and an NPV of 94%. This studys limitations include its retrospective design and interobserver variability inherent to cystoscopy, which was used as the reference test. CONCLUSIONS When used as a reflex test on atypical urine cytology, negative uCyt may predict a negative cystoscopy in select patients and modulate the urgency and further work-up in those with no prior history or low-grade disease.

Updated Trends in Imaging Use in Men Diagnosed with Prostate Cancer

Background:Previous studies have found persistent overuse of imaging for clinical staging of men with low-risk prostate cancer. We aimed to determine imaging trends in three cohorts of men.Methods:We analyzed imaging trends of men with prostate cancer who were a part of Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) (1998–2006), were insured by Medicare (1998–2006), or privately insured (Ingenix database, 2002–2006). The rates of computed tomography (CT), magnetic resonance imaging (MRI) and bone scan (BS) were determined and time trends were analyzed by linear regression. For men in CaPSURE, demographic and clinical predictors of test use were explored using a multivariable regression model.Results:Since 1998, there was a significant downward trend in BS (16%) use in the CaPSURE cohort (N=5156). There were slight downward trends (2.4 and 1.7%, respectively) in the use of CT and MRI. Among 54 322 Medicare patients, BS, CT and MRI use increased by 2.1, 10.8 and 2.2% and among 16 161 privately insured patients, use increased by 7.9, 8.9 and 3.7%, respectively. In CaPSURE, the use of any imaging test was greater in men with higher-risk disease. In addition, type of insurance and treatment affected the use of imaging tests in this population.Conclusions:There is widespread misuse of imaging tests in men with low-risk prostate cancer, particularly for CT. These findings highlight the need for examination of factors that drive decision making with respect to imaging in this setting.

Misclassification of bronchioloalveolar carcinoma with cytologic diagnosis of lung cancer.

Introduction: Cytology is commonly used to diagnose non-small cell lung cancer (NSCLC) but is an inaccurate means of diagnosis of bronchioloalveolar carcinoma (BAC). The aims of this study were to calculate the sensitivity and specificity of cytologic diagnosis of BAC and to estimate the misclassification of BAC as other subtypes of NSCLC. Methods: Preoperative fine-needle aspiration cytology diagnoses were compared to histology diagnoses in 222 patients, including 51 patients with pure or mixed BAC, who underwent lung resection for NSCLC at our institution since 1999. Results: The sensitivity and specificity of a cytologic diagnosis of BAC were 12% and 99%, respectively. Based on cytologic diagnosis, 63% of BAC was misclassified as adenocarcinoma, and 18% was misclassified as undifferentiated NSCLC. In this cohort, 35% of adenocarcinomas and 12% of undifferentiated NSCLC diagnosed by cytology had BAC histology. Conclusions: Diagnosis of NSCLC by cytology alone results in significant misclassification of BAC, most commonly as adenocarcinoma or undifferentiated NSCLC. Because patients with BAC respond differently to certain treatments such as endothelial growth factor receptor inhibitors and surgical resection of multifocal lung cancer, misclassification of BAC may have important therapeutic implications.

Temporal and geospatial trends in male factor infertility with assisted reproductive technology in the United States from 1999–2010

OBJECTIVE To estimate the prevalence of male factor infertility diagnosis within the context of assisted reproductive technology (ART) clinics and its geographic and temporal distribution from 1999-2010. DESIGN Population study based on patients presenting for care at ART centers. SETTING Clinics providing ART services. PATIENT(S) All male patients seeking infertility care at ART clinics. INTERVENTION(S) Data were obtained from the Centers for Disease Control and Prevention, analyzed, geocoded, and mapped. MAIN OUTCOME MEASURE(S) Prevalence of male factor infertility diagnosis in a couple seeking infertility care. RESULT(S) Between 1999 and 2010, 1,057,402 cycles of ART using nonfrozen, nondonor eggs were performed, increasing from 62,809 cycles in 1999 to 99,289 cycles in 2010. Nationwide in ART clinics, the period prevalence of isolated male factor infertility was 17.1% and the prevalence of overall male factor infertility diagnoses was 34.6%. The highest prevalence was reported in New Mexico (56.4%) and lowest in Mississippi (24.2%). CONCLUSION(S) The prevalence of male factor infertility diagnosis varies significantly by time and space within the United States, whereas its overall prevalence has remained remarkably stable. This study provides the spatial analytic framework for future research to explore factors associated with male factor infertility.

Inguinal herniation of a transplant ureter.

Anobel Y. Odisho, Christopher E. Freise, Stephen J. Tomlanovich and Parsia A. Vagefi Department of Surgery, University of California, San Francisco Medical Center, San Francisco, California, USA; Division of Transplant Surgery, University of California, San Francisco Medical Center, San Francisco, California, USA and Division of Nephrology, University of California, San Francisco Medical Center, San Francisco, California, USA Correspondence: Parsia A. Vagefi, Department of Surgery, University of California, San Francisco Medical Center, 505 Parnassus Avenue, San Francisco, California 94143, USA. E-mail: parsia.vagefi@ucsfmedctr.org

Variation in prostate cancer treatment associated with population density of the county of residence.

Background:We sought to assess variation in the primary treatment of prostate cancer by examining the effect of population density of the county of residence on treatment for clinically localized prostate cancer and quantify variation in primary treatment attributable to the county and state level.Methods:A total 138 226 men with clinically localized prostate cancer in the Surveillance, Epidemiology and End Result (SEER) database in 2005 through 2008 were analyzed. The main association of interest was between prostate cancer treatment and population density using multilevel hierarchical logit models while accounting for the random effects of counties nested within SEER regions. To quantify the effect of county and SEER region on individual treatment, the percent of total variance in treatment attributable to county of residence and SEER site was estimated with residual intraclass correlation coefficients.Results:Men with localized prostate cancer in metropolitan counties had 23% higher odds of being treated with surgery or radiation compared with men in rural counties, controlling for number of urologists per county as well as clinical and sociodemographic characteristics. Three percent (95% confidence interval (CI): 1.2–6.2%) of the total variation in treatment was attributable to SEER site, while 6% (95% CI: 4.3–9.0%) of variation was attributable to county of residence, adjusting for clinical and sociodemographic characteristics.Conclusions:Variation in treatment for localized prostate cancer exists for men living in different population-dense counties of the country. These findings highlight the importance of comparative effectiveness research to improve understanding of this variation and lead to a reduction in unwarranted variation.