Christer Ahlstrand

Clinical characteristics and primary treatment of prostate cancer in Sweden between 1996 and 2005

Objective. The incidence of prostate cancer is rising rapidly in Sweden and there is a need to better understand the pattern of diagnosis, tumor characteristics and treatment. Material and methods. Between 1996 and 2005, all new cases of adenocarcinoma of the prostate gland were intended to be registered in the National Prostate Cancer Register (NPCR). This register contains information on diagnosing unit, date of diagnosis, cause of diagnosis, tumor grade, tumor stage according to the TNM classification in force, serum prostate-specific antigen (PSA) levels at diagnosis and primary treatment given within the first 6 months after diagnosis. Results. In total, 72 028 patients were registered, comprising >97% of all pertinent incident cases of prostate cancer in the Swedish Cancer Register (SCR). During the study period there was a considerable decrease in median age at the time of diagnosis, a stage migration towards smaller tumors, a decrease in median serum PSA values at diagnosis, a decrease in the age-standardized incidence rate of men diagnosed with distant metastases or with a PSA level of >100 ng/ml at diagnosis and an increase in the proportion of tumors with Gleason score ≤6. Relatively large geographical differences in the median age at diagnosis and the age-standardized incidence of cases with category T1c tumors were observed. Treatment with curative intent increased dramatically and treatment patterns varied according to geographical region. In men with localized tumors and a PSA level of <20 ng/ml at diagnosis, expectant treatment was more commonly used in those aged ≥75 years than in those aged <75 years. Also, the pattern of endocrine treatment varied in different parts of Sweden. Conclusions. All changes in the register seen over time are consistent with increased diagnostic activity, especially PSA testing, resulting in an increased number of cases with early disease, predominantly tumors in category T1c. The patterns of diagnosis and treatment of prostate cancer vary considerably in different parts of Sweden. The NPCR continues to be an important source for research, epidemiological surveillance of the incidence, diagnosis and treatment of prostate cancer

Renal Stone Disease in a Swedish District During One Year

In a Swedish district served by only one hospital the annual incidence of urinary stone colic was estimated to 1.4 per 1000 inhabitants. Sixty-two per cent of the patients were treated entirely as out patients whereas 9% required some form of surgery during the study. Thirty-seven per cent of the patients were recurrent stone formers. No significant seasonal variation in stone incidence was noted. A definite reason for stone formation could be established in 6%, and among 56 patients with recurrent stone disease run through a biochemical investigation, abnormal findings were recorded in 70%.

Relative importance of sources of symptom-induced distress in urinary bladder cancer survivors

OBJECTIVE The influence of specific symptoms on emotions and social activities in the individual patient varies. Little is known about this variation in urinary bladder cancer survivors (in other words, about the relative importance of sources of symptom-induced distress). METHODS We attempted to enroll 404 surgical patients treated with cystectomy and a conduit or reservoir in four Swedish towns (Stockholm, Orebro, Jönköping, Linköping), 101 surgical patients treated with cystectomy and orthotopic neobladder at the Herlev Hospital in Copenhagen, Denmark, and 71 patients treated with radical radiotherapy for bladder cancer, as well as 581 men and women controls in Stockholm and Copenhagen. An anonymous postal questionnaire was used to collect the information. RESULTS A total of 503 out of 576 (87%) treated patients and 422 out of 581 (73%) controls participated but 59 patients were excluded. The primary source of self-assessed distress among cystectomised patients was compromised sexual function; reduced intercourse frequency caused great distress in 19% of the conduit patients, 20% of the reservoir patients and 19% of the bladder substitute patients. The primary source of self-assessed distress in patients treated with radical radiotherapy was symptoms from the bowel; 17% reported great distress due to diarrhoea, 16% due to abdominal pain, 14% due to defecation urgency and 14% due to faecal leakage. The highest proportion of subjects being distressed was 93% (substantial: 43%, moderate: 29% and little: 21%) for treated upper or lower urinary retention (indwelling catheter or nephrostomy). CONCLUSION The distress caused by a specific symptom varies considerably and the prevalence of symptoms causing great distress differs between treatments in bladder cancer survivors. It is possible that patient care and clinical research can be made more effective by focusing on important sources of symptom-induced distress.

Urine Composition and Stone Formation During Treatment with Acetazolamide

Twelve patients who formed renal stones during acetazolamide treatment for glaucoma were studied. Calcium phosphate was the dominating component in the stones. Long term treatment with acetazolamide decreased urinary citrate markedly, which will result in an increased ion-activity product of calcium phosphate and a decreased inhibiting property of urine on calcium phosphate crystallization. The treatment also increased urinary oxalate which together with a low citrate might increase the risk of calcium oxalate crystallization. However, an estimate of the ion-activity product of calcium oxalate in urine (AP [CaOx]-index) was unaffected by the treatment and calcium oxalate was a minor component of the stones.

Variations in urine composition during the day in patients with calcium oxalate stone disease.

The diurnal variations of urine composition with respect to calcium, magnesium, oxalate, citrate and inhibition of calcium oxalate crystal growth were studied in patients with recurrent calcium oxalate stone disease. There was considerable variation in the excretion of the different urine constituents with meal-related peaks, which was most pronounced for calcium. The highest concentration of calcium was observed before noon, and between 7 and 11 p.m. Oxalate concentration was highest between 6 and 10 a.m. Consequently, the highest levels of supersaturation were recorded between 6 and 10 a.m., and 6 and 10 p.m. The inhibition index was at the highest level during the first morning hours and could be important in counteracting crystal growth at that time. The risk of exceeding a theoretical formation product of calcium oxalate appeared to be low, with a 24-hour urine volume more than 2,000 ml.

Time after surgery, symptoms and well-being in survivors of urinary bladder cancer

To evaluate how an increasing burden of symptoms influences well‐being, anxiety and depression at different intervals after a radical cystectomy with urostomy for bladder cancer, as this therapy can induce long‐term distressful symptoms.

Benign prostatic hyperplasia in sweden 1987 to 1994: changing patterns of treatment, changing patterns of costs

OBJECTIVES To assess health care use and costs for benign prostatic hyperplasia (BPH) in Sweden from 1987 to 1994 when minimal invasive procedures, including transurethral microwave therapy (TUMT) and drugs, were introduced, in addition to conventional surgery. METHODS Cross-sectional annual data on health care utilization based on national information systems and surveys were used for calculation of direct 1994 cost. RESULTS The total number of men in the age group at risk for BPH was virtually constant, and the total direct health care costs for BPH treatment increased from 1987 to 1992. A slight decrease was evident for the years 1993 and 1994, notwithstanding the introduction of new ambulatory procedures in 1991 and of new drugs in 1992. The number of physician office visits changed little during the study period, although this estimate may be low. TUMT procedures were introduced rapidly but decreased; nevertheless, their share was never more than 3% of total costs. Drug sales were 15-fold those in 1992 and accounted for 12% of the total costs in 1994. Conventional transurethral resection of the prostate (TURP) operations decreased markedly after the introduction of the new treatments. CONCLUSIONS The new treatments were adopted differently. TUMT procedures decreased as rapidly as they were introduced. Three years after the introduction of the new drugs, drug sales indicated that the number of men receiving drug treatment was greater than the annual number of men receiving TURP operations and TUMT procedures combined. Yet the total costs showed a slight decrease, mainly due to the decreasing numbers of TURP operations.

An estimate of the life-time cost of surgical treatment of patients with benign prostatic hyperplasia in Sweden.

Two clinical series (n = 96 + 90) and one record-linkage study (n = 492) were used for estimation of the health care utilization for the treatment of BPH patients, mainly by TURP, in Sweden during one year before and 5-7 years after surgery. The total cost for a single patient amounted to ca. 33000 SEK in 1900 prices (5850 USD). Costs for surgery dominated and for a TURP amounted to about 70% of the Total. The costs during one year preoperatively and 5 years postoperatively each amounted to 15% of the total costs. In the present study the outcome of surgery was similar to other reports from the same period. The surgical mortality was 0.4% and the readmission rate because of complications of surgery or manifestations of BPH was 25% after 7 years of observation. Of the patients 11% were reoperated on within 7 years. When transurethral resection of the prostate (TURP) replaced open surgery in Sweden during the 1970s it had several of the attributes of the new methods introduced for treatment of benign prostate hyperplasia (BPH) currently in use. However, the spread of TURP resulted in wider indications for surgery and an increase in the total number of surgical procedures. An important argument for the adoption of the new, less invasive methods for treatment of BPH is the lower cost. To make a fair comparison of the costs of different methods for treatment of BPH the long-term costs have to be included in the calculation.

Nationwide population-based study on 30-day mortality after radical prostatectomy in Sweden.

Objective. The incidence of prostate cancer in Sweden is increasing rapidly, as is treatment with curative intent. Radical prostatectomy (RP) is currently commonly performed, either within or outside large high-volume centres. The aim of this study was to assess the 30-day mortality rate after RP in Sweden. Material and methods. In this nationwide population-based study, all men diagnosed with localized prostate cancer (≤70 years, clinical stadium T1–2, prostate-specific antigen <20 ng/ml) who underwent RP in Sweden between 1997 and 2002 were identified through the National Prostate Cancer Register (NPCR). Mortality within 30 days of RP was analysed through linkage between the follow-up study of the NPCR and the Regional Population Registers. The cause of death in the death certificates were compared with data from the hospitals concerned. To validate the results, a record linkage between the Inpatient Register and the National Population Register was also performed. Results. The number of RPs performed increased over time. Among 3700 RPs performed, four deaths occurred during the first 30 days, yielding a 0.11% 30-day mortality rate. These deaths occurred at three different types of hospital and were all probably related to the RP. Conclusion. This study provides further evidence that RP is a procedure with very low perioperative mortality even when performed outside high-volume centres.

Defecation disturbances after cystectomy for urinary bladder cancer

Study Type – Preference (prospective cohort)