Christopher B. Anderson

Angiomyolipomata: challenges, solutions, and future prospects based on over 100 cases treated.

Study Type – Therapy (case series) Level of Evidence 4

Age is Associated with Upgrading at Confirmatory Biopsy among Men with Prostate Cancer Treated with Active Surveillance

PURPOSE Active surveillance is increasingly recommended for older men with low risk prostate cancer. Although older men have higher all cause mortality, they also have higher prostate cancer specific mortality. We hypothesized that older age is associated with an increased risk of Gleason score upgrading at confirmatory biopsy when controlling for prostate volume. MATERIALS AND METHODS We retrospectively reviewed data on 1,130 patients with prostate cancer who were treated with active surveillance from 1991 through 2011. We included 646 patients with clinical Gleason 6 or less, stage T2a or less prostate cancer, a confirmatory biopsy within 2 years of diagnostic biopsy and prostate magnetic resonance imaging before confirmatory biopsy. The primary outcome was Gleason score upgrading to 7 or greater on confirmatory biopsy. We used logistic regression to estimate the effect of age on upgrading, adjusting for magnetic resonance imaging prostate volume and other potential confounders. RESULTS Median age was 66 years (IQR 61-72) and median magnetic resonance imaging prostate volume was 41 ml (IQR 29-55). At confirmatory biopsy disease was upgraded in 55 of 646 patients (9%) and unchanged in 290 (45%) and biopsy was negative in 297 (46%). Older age was associated with higher odds of upgrading (adjusted OR 1.05, 95% CI 1.01-1.09, p=0.009). Larger prostate volume was associated with lower odds of upgrading (adjusted OR 0.80/10 ml increase, 95% CI 0.7-0.9, p=0.012). CONCLUSIONS Our findings suggest that older age is associated with an increased risk of misclassification on diagnostic biopsy. Older men who are interested in active surveillance should be counseled about the risks and benefits of confirmatory biopsy.

Impact of Surgeon Case Volume on Reoperation Rates after Inflatable Penile Prosthesis Surgery

Purpose: We investigated the impact of surgeon annual case volume on reoperation rates after inflatable penile prosthesis surgery. Materials and Methods: The New York Statewide Planning and Research Cooperative System database was queried for inflatable penile prosthesis cases from 1995 to 2014. Multivariate proportional hazards regression was performed to estimate the impact of surgeon annual case volume on inflatable penile prosthesis reoperation rates. We stratified our analysis by indication for reoperation to determine if surgeon volume had a similar effect on infectious and noninfectious complications. Results: A total of 14,969 men underwent inflatable penile prosthesis insertion. Median followup was 95.1 months (range 0.5 to 226.7) from the time of implant. The rates of overall reoperation, reoperation for infection and reoperation for noninfectious complications were 6.4%, 2.5% and 3.9%, respectively. Implants placed by lower volume implanters were more likely to require reoperation for infection but not for noninfectious complications. Multivariable analysis demonstrated that compared with patients treated by surgeons in the highest quartile of annual case volume (more than 31 cases per year), patients treated by surgeons in the lowest (0 to 2 cases per year), second (3 to 7 cases per year) and third (8 to 31 cases per year) annual case volume quartiles were 2.5 (p <0.001), 2.4 (p <0.001) and 2.1 (p=0.01) times more likely to require reoperation for inflatable penile prosthesis infection, respectively. Conclusions: Patients treated by higher volume implanters are less likely to require reoperation after inflatable penile prosthesis insertion than those treated by lower volume surgeons. This trend appears to be driven by associations between surgeon volume and the risk of prosthesis infection.

Association between number of prostate biopsies and patient-reported functional outcomes after radical prostatectomy: implications for active surveillance protocols.

To evaluate whether the number of preoperative prostate biopsies affects functional outcomes after radical prostatectomy (RP).

Performance of a Trigger Tool for Identifying Adverse Events in Oncology.

PURPOSE Although patient safety is a priority in oncology, few tools measure adverse events (AEs) beyond treatment-related toxicities. The study objective was to assemble a set of clinical triggers in the medical record and assess the extent to which triggered events identified AEs. METHODS We performed a retrospective cohort study to assess the performance of an oncology medical record screening tool at a comprehensive cancer center. The study cohort included 400 patients age 18 years or older diagnosed with breast (n = 128), colorectal (n = 136), or lung cancer (n = 136), observed as in- and outpatients for up to 1 year. RESULTS We identified 790 triggers, or 1.98 triggers per patient (range, zero to 18 triggers). Three hundred four unique AEs were identified from medical record reviews and existing AE databases. The overall positive predictive value (PPV) of the original tool was 0.40 for total AEs and 0.15 for preventable or mitigable AEs. Examples of high-performing triggers included return to the operating room or interventional radiology within 30 days of surgery (PPV, 0.88 and 0.38 for total and preventable or mitigable AEs, respectively) and elevated blood glucose (> 250 mg/dL; PPV, 0.47 and 0.40 for total and preventable or mitigable AEs, respectively). The final modified tool included 49 triggers, with an overall PPV of 0.48 for total AEs and 0.18 for preventable or mitigable AEs. CONCLUSION A valid medical record screening tool for AEs in oncology could offer a powerful new method for measuring and improving cancer care quality. Future improvements could optimize the tools efficiency and create automated electronic triggers for use in real-time AE detection and mitigation algorithms.

Long-term Survival Outcomes With Intravesical Nanoparticle Albumin-bound Paclitaxel for Recurrent Non–muscle-invasive Bladder Cancer After Previous Bacillus Calmette-Guérin Therapy

OBJECTIVE To report long-term follow-up results of a phase II trial of salvage intravesical nanoparticle albumin-bound (nab)-paclitaxel for patients with recurrent non-muscle-invasive bladder cancer after previous intravesical bacillus Calmette-Guérin (BCG) therapy. METHODS This was a phase II trial investigating the use of intravesical nab-paclitaxel in patients with recurrent Tis, Ta, and T1 urothelial carcinoma who failed at least 1 prior induction course of intravesical BCG. Patients received 500 mg/100 mL of nab-paclitaxel in 6 weekly intravesical instillations. Complete responders were offered full-dose maintenance for 6 months. Overall survival, recurrence-free survival, cystectomy-free survival, and cancer-specific survival were assessed via Kaplan-Meier analysis. RESULTS A total of 28 patients were enrolled with a median follow-up of 41 months (range 5-76). There were 22 men and 6 women with a median age of 79 (range 36-93), and the median number of prior intravesical therapies was 2. Twenty-one of the 28 patients (75%) were BCG refractory. Ten of the 28 patients (36%) achieved complete response. Six of the 28 patients remain cancer free, with a recurrence-free survival rate of 18%. Five-year overall and cancer-specific survival rates were 56% and 91%, respectively. Radical cystectomy occurred in 11 of the 28 patients (39%), of whom 2 out of 11 (18%) had pT2 or greater disease. CONCLUSION With a median follow-up of 41 months, 18% of this cohort treated with nab-paclitaxel was disease free. Cystectomy-free survival was 61% and bladder cancer-specific mortality was 9%. Nab-paclitaxel is a reasonable treatment option in this high-risk population.

Outcomes and Prognostic Factors of Primary Urethral Cancer

OBJECTIVE To identify prognostic and treatment factors for primary urethral cancer using a nationwide database. MATERIALS AND METHODS The National Cancer Database was queried for all cases of primary urethral cancer from 2004 to 2013. Patients with other cancer diagnoses, metastasis, or diagnosis on autopsy were excluded. Proportional hazards regression was used to identify independent predictors of overall survival in patients with primary urethral cancer. Because we hypothesized that predictors may covary by sex, we also performed regression analysis stratified by sex. RESULTS We identified 1268 men and 869 women with primary urethral cancer. Women tended to have more advanced tumors and adenocarcinoma histology. Median survival for the entire cohort was 49 months (43-55), with 5- and 10-year survival rates of 46% and 31%, respectively. On multivariate analysis, age, race, stage, grade, and Charlson comorbidity index were independent predictors of overall survival. Histology was not a predictor of overall survival in the combined model; however, adenocarcinoma in women increased hazards of death, whereas it decreased hazards of death in men when compared with squamous cell carcinoma. CONCLUSION Men and women with primary urethral cancer had significant differences in histology, grade, and nodal status. In addition to several expected disease-related factors, black race was associated with increased mortality for patients with primary urethral cancer.

Regionalization of radical cystectomy in the United States

PURPOSE Radical cystectomy (RC) has become increasingly regionalized to high-volume hospitals. Our objective was to describe changes in regional market concentration and the distribution of RCs among hospitals, and examine how these changes affect patient travel distance to surgery. MATERIALS AND METHODS We used the surveillance, epidemiology, and end results-Medicare database to identify patients who had RC for bladder cancer from 2001 to 2011. We defined RC market concentration within each Hospital Referral Regions (HRR) in surveillance, epidemiology, and end results using the Hirschman-Herfindhal Index. We measured straight-line patient travel distance to the nearest cystectomy provider hospital and used linear regression to evaluate the effect of market concentration on travel distance for surgery. We performed a similar analysis on patients who had laparoscopic cholecystectomy as a comparator. RESULTS We identified 10,802 patients with bladder cancer who had RC. From 2001 to 2011, 40% of HRRs had a statistically significant increase in Hirschman-Herfindhal Index, 53% had no significant change and 7% had a statically significant decrease. The median patient travel distance increased significantly from 10.4 miles (interquartile range: 2.6-30.2) to 16 miles (interquartile range: 6.3-40.4, P<0.0001). Patients who lived in a highly concentrated HRR had to travel significantly further than patients who lived in an unconcentrated HRR (β = 37.5, P<0.001). These trends were not seen for laparoscopic cholecystectomy. CONCLUSIONS Between 2001 and 2011, RC became increasingly regionalized to a small group of hospitals with a resultant increase in regional RC market concentration and patient travel distance. The clinical consequences on these changes to patients who require RC are uncertain.

Idiographic quality of life assessment before radical cystectomy.

We sought to determine if idiographic, or self‐defined, measures added to our understanding of patients with bladder cancers quality of life (QOL) prior to radical cystectomy (RC). We tested whether idiographic measures increased prediction of global QOL beyond standard (nomothetic) measures of QOL components.

Use of Adjuvant Chemotherapy in Patients with Advanced Bladder Cancer after Neoadjuvant Chemotherapy

Objectives: To compare the outcomes of adjuvant chemotherapy (AC) versus observation in patients with non-organ confined disease after neoadjuvant chemotherapy and radical cystectomy (RC). Materials and methods: Using the National Cancer Database, we identified patients who received NAC prior to RC and had advanced stage (pT3/4) or pathologically involved nodes (pN+) at the time of surgery from 2004–2013. We determined whether patients then received AC or were managed with observation only and used multivariable proportional hazards regression to estimate the impact of AC on overall survival. Results: Overall 34% (N = 705) of patients who received NAC and underwent RC were pT3/4 and/or pN+. Of these patients, 24% (N = 168) received subsequent chemotherapy and the rest were observed. Median survival for the entire cohort was 21 months (IQR 12–45). There was not a statistically significant difference in median survival between the AC and observation groups (23 months [IQR 14–46] versus 20 months [IQR 12–46], log-rank p = 0.52). On multivariate analysis there was no survival advantage for the AC cohort. Subgroup analysis of pN+ patients who received AC also did not show a survival advantage. Conclusions: Patients who are pT3/4 and/or pN+ after NAC and RC have a poor prognosis. The addition of AC does not seem to be beneficial. Further research should focus identifying patients who may benefit from additional chemotherapy.