Audrey Rhee

Predicting clinical end points: treatment nomograms in prostate cancer.

Due to the generally indolent nature of prostate cancer, patients must decide among a wide range of treatments, which will significantly affect both quality of life and survival. Thus, there is a need for instruments to aid patients and their physicians in decision analysis. Nomograms are instruments that predict outcomes for the individual patient. Using algorithms that incorporate multiple variables, nomograms calculate the predicted probability that a patient will reach a clinical end point of interest. Nomograms tend to outperform both expert clinicians and predictive instruments based on risk grouping. We outline principles for nomogram construction, including considerations for choice of clinical end points and appropriate predictive variables, and methods for model validation. Currently, nomograms are available to predict progression-free probability after several primary treatments for localized prostate cancer. There is need for additional models that predict other clinical end points, especially survival adjusted for quality of life.

Prognostic factors for survival in patients with hormone-refractory prostate cancer (HRPC) after initial androgen deprivation therapy (ADT)

Androgen deprivation therapy (ADT) is a standard mode of therapy for patients with metastatic prostate cancer. Controversy exists, however, as to the optimal timing of initiation of ADT, as well as whether this form of therapy imparts a survival benefit to patients with advanced disease. Side effects of ADT are not minimal and can seriously compromise a patients quality of life. Additionally, ADT eventually results in hormone-refractory prostate cancer (HRPC). Despite new chemotherapeutic regimens and hormonal agents, overall survival in these patients remains universally low. Nonetheless, it is valuable to gauge a patients prognosis to assist in decision making when considering treatment options. Contemporary series analyzing patients with HRPC have identified several factors prognostic of survival outcomes, such as lactate dehydrogenase (LDH), alkaline phosphatase (ALK), hemoglobin (Hgb), and serum prostate specific antigen (PSA) level. Nomograms have been developed that utilize these pretreatment clinical variables to predict clinical outcomes, including 1-year, 2-year, and median survival times in patients with HRPC. These instruments are capable of more accurately predicting survival outcomes than traditional tables of multivariate results or simple analysis of prognostic factors. We believe these nomograms will become indispensable tools for patient counseling and clinical trial design in patients with HRPC.

Do Routine Preoperative and Intraoperative Urine Cultures Benefit Pediatric Vesicoureteral Reflux Surgery

Objective. To determine if routine preoperative and intraoperative urine cultures (UCx) are necessary in pediatric vesicoureteral (VUR) reflux surgery by identifying their association with each other, preoperative symptoms, and surgical outcomes. Materials and Methods. A retrospective review of patients undergoing ureteral reimplant(s) for primary VUR at a tertiary academic medical center between years 2000 and 2014 was done. Preoperative UCx were defined as those within 30 days before surgery. A positive culture was defined as >50,000 colony forming units of a single organism. Results. A total of 185 patients were identified and 87/185 (47.0%) met inclusion criteria. Of those, 39/87 (45%) completed a preoperative UCx. Only 3/39 (8%) preoperative cultures returned positive, and all of those patients were preoperatively symptomatic. No preoperatively asymptomatic patients had positive preoperative cultures. Intraoperative cultures were obtained in 21/87 (24.1%) patients; all were negative. No associations were found between preoperative culture results and intraoperative cultures or between culture result and postoperative complications. Conclusions. In asymptomatic patients, no associations were found between the completion of a preoperative or intraoperative UCx and surgical outcomes, suggesting that not all patients may require preoperative screening. Children presenting with symptoms of urinary tract infection (UTI) prior to ureteral reimplantation may benefit from preoperative UCx.