Cameron Ghaffary

Survival differences among patients with bladder cancer according to sex: Critical evaluation of radical cystectomy use and delay to treatment

OBJECTIVE Sex differences in bladder cancer survival are well known. However, the effect of type of treatment, timing to surgery when rendered, and survival outcomes according to sex have not been extensively examined. Given the relatively low incidence of bladder cancer in females, large multicenter and population-based studies are required to elucidate sex differences in survival. In this study, we sought to characterize the effect of use and timing of radical cystectomy (RC) according to sex and survival outcomes. METHODS A total of 9,907 patients aged 66 years or older diagnosed with clinical stage II to IV N0M0 bladder cancer from January 1, 2001 to December 31, 2011 from Surveillance, Epidemiology, and End Results-Medicare data were analyzed. We used multivariable regression analyses to identify factors predicting the use and delay of RC. Cox proportional hazards models were used to analyze survival outcomes. RESULTS Of the 9,907 patients diagnosed with bladder cancer, 3,256 (32.9%) were females. Women were significantly more likely to undergo RC across all stages compared to their male counterparts (stage II: relative risk [RR] = 1.48, 95% CI: 1.33-1.65, P<0.001; stage III: RR = 1.24, 95% CI: 1.13-1.37, P<0.001; and stage IV: RR = 1.33, 95% CI: 1.19-1.49, P<0.001). Moreover, there was no significant difference in delay to RC according to sex across all clinical stages. Using propensity score matching, women had worse overall (hazard ratio = 1.07; CI: 1.01-1.14; P = 0.024), and worse cancer-specific survival (hazard ratio = 1.26; CI: 1.17-1.36, P<0.001) than men. CONCLUSION Sex differences persist with women who are significantly more likely to undergo RC independent of clinical stage. However, women have significantly worse survival than men. Delay from diagnosis to surgery did not account for this decreased survival among women.

Synchronous Renal Cell Carcinoma and Gastrointestinal Malignancies

While renal cell carcinoma is the most commonly diagnosed neoplasm of the kidney, its simultaneous diagnosis with a gastrointestinal malignancy is a rare, but well reported phenomenon. This discussion focuses on three independent cases in which each patient was diagnosed with renal cell carcinoma and a unique synchronous gastrointestinal malignancy. Case 1 explores the diagnosis and surgical intervention of a 66-year-old male patient synchronously diagnosed with clear cell renal cell carcinoma and a carcinoid tumor of the small bowel. Case 2 describes the diagnosis and surgical intervention of a 61-year-old male found to have clear cell renal cell carcinoma and a mucinous appendiceal neoplasm. Lastly, Case 3 focuses on the interventions and management of a 36-year-old female diagnosed with synchronous clear cell renal carcinoma and hereditary nonpolyposis colorectal cancer. This case series examines each distinct patients presentation, discusses the diagnosis, and compares and contrasts the findings while discussing the literature on this topic.

MP21-11 INCREASED UTILIZATION OF ADVANCED IMAGING TECHNOLOGY AND ITS ECONOMIC IMPACT FOR PATIENTS DIAGNOSED WITH BLADDER CANCER IN THE UNITED STATES

vs 8.4 4.8 days no readmission, p1⁄40.003), there was no significant relationship after adjusting for other factors (20.6% 0-6 days vs 19.5% 10+ days, adjusted OR 1.03, 95% 0.79-1.35, Figure). A subset analysis examining only surgery-related readmissions demonstrated similar findings. CONCLUSIONS: If no in-hospital complications occur following radical cystectomy, applying arbitrary minimum thresholds for length of stay may not decrease the risk of hospital readmission.

MP47-12 IMPACT OF PROXIMITY TO NCI- AND NCCN-DESIGNATED CANCER CENTERS ON OUTCOMES FOR PATIENTS WITH PROSTATE CANCER UNDERGOING RADICAL PROSTATECTOMY

(Graphpad prism software). Progression free survival was estimated using Kaplan-Meier curves (SPSS software). RESULTS: 1260 men were reviewed (mean age 62.4 years; mean PSA 9.8 ng/dL). The overall PCa detection rate was 57.2% (n 1⁄4 721). 517 men had available treatment data and either entered AS (38.9%, n1⁄4201), received RP (40.2%, n1⁄4208), RT þ/ADT (10.6, n1⁄455), medical treatment (7.9%, n1⁄441), or FLA (2.32%, n1⁄412). The age, PSA, Gleason Scores (GI), and imaging characteristics are described for each of these groups in Table 1. Younger patients were more likely to choose RP over AS or RT (p<0.0001). The median PSA for those who received RT was higher than those on AS or who received RP (p<0.0001). The mean estimated progression free survival for AS was 105 months. The mean estimated BCR free survival was 71 months and 96 months for RP and RT, respectively (p1⁄40.02). FBx upgrade (FBx GI > standard biopsy (SBx) GI) was significantly more common in patients who received either RP or RT when compared to SBx upgrade (p<0.0001). CONCLUSIONS: MRI/TRUS-FBx use in the diagnosis of PCa results in more accurate assessment of disease burden and modulates treatment modality chosen by patients. FBx upgrade occurred in an increased proportion of patients choosing either RP or RT over AS. Further study is required to delineate the use and benefits of FBx when counseling patients on management options.

Re: Jim C. Hu, Bilal Chughtai, Padraic O’Malley, et al. Perioperative Outcomes, Health Care Costs, and Survival After Robotic-assisted Versus Open Radical Cystectomy: A National Comparative Effectiveness Study. Eur Urol 2016;70:195–202: Comparative Effectiveness of Robotic-assisted versus Open Radical Cystectomy: Big Data but Meaningful Conclusions?

Comparative effectiveness research is in high demand and is a litmus test to optimize mandates set forth by current health care reform initiatives [1]. The Institute of Medicine has placed comparative effectiveness research as a US national priority and many would argue this is an international priority in order to optimize outcomes and reduce costs associated with health care delivery [2]. The US National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine held a workshop entitled ‘‘Appropriate Use of Advanced Technologies for Radiation Therapy and Surgery in Oncology’’ in July 2015 [3]. There are immense challenges in which costs of surgical treatments pose, particularly as our complex and expensive technologies continue to evolve. With sharply rising costs of cancer treatment, appropriate use of new treatment technologies including robotic surgery, serves as a beacon to promote value in cancer treatment [1]. In their Platinum Priority article, Hu et al [4] present a retrospective population-based assessment using the Surveillance, Epidemiologic, and End Results (SEER)Medicare linked database from 2002 to 2012 in order to identify bladder cancer patients treated with either robotic (RARC) or open (ORC) radical cystectomy [4]. Using propensity score matching, they compared utilization, complications, perioperative cost, and survival outcomes between RARC and ORC. As seen in the robotic prostatectomy literature [5], there was a surge in rates of RARC utilization over the study period. Moreover, RARC resulted in equivalent oncologic outcomes, less hospital stay, greater lymph node yield, with comparable complication rates albeit at higher costs than ORC. The authors appropriately note these results are hypothesis generating and further support the current randomized controlled