Christopher P. Filson

Prostate cancer detection with magnetic resonance-ultrasound fusion biopsy: The role of systematic and targeted biopsies.

The current study was conducted to evaluate the performance of magnetic resonance (MR)‐ultrasound‐guided fusion biopsy in diagnosing clinically significant prostate cancer (csCaP).

Variation in Use of Active Surveillance among Men Undergoing Expectant Treatment for Early Stage Prostate Cancer

PURPOSE We examined variation in active surveillance use in Medicare eligible men undergoing expectant treatment for early stage prostate cancer. MATERIALS AND METHODS Using SEER (Surveillance, Epidemiology and End Results) and Medicare data we identified 49,192 men diagnosed with localized prostate cancer from 2004 through 2007. Of 7,347 patients who did not receive treatment (ie expectant management) within 12 months of diagnosis we assessed the prevalence of active surveillance (ie repeat prostate biopsy and prostate specific antigen measurement) vs watchful waiting across health care markets. We fit multivariable logistic regression models to examine associations of active surveillance with patient demographics, cancer severity and health care market characteristics. RESULTS During the study interval use of active surveillance vs watchful waiting increased significantly in patients treated expectantly from 9.7% in 2004 to 15.3% in 2007 (p <0.001). Active surveillance was less common in older patients, those with high risk tumors and those with more comorbidities (each p <0.001). Patients who were white and had higher socioeconomic status were more likely to receive active surveillance (each p <0.05). After adjusting for patient and tumor characteristics significant differences in the predicted probability of active surveillance persisted across health care markets (range 2.4% to 30.1%). No significant variation in active surveillance use was associated with specific health care market characteristics, including intensity of end of life care, Medicare reimbursement or provider density. CONCLUSIONS Active surveillance has been relatively uncommon in Medicare beneficiaries with localized prostate cancer. Its use relative to watchful waiting varies based on patient demographics, tumor severity and geographic location.

Technique and Outcomes of Robot-assisted Retroperitoneoscopic Partial Nephrectomy: A Multicenter Study

BACKGROUND Robot-assisted retroperitoneoscopic partial nephrectomy (RARPN) may be used for posterior renal masses or with prior abdominal surgery; however, there is relatively less familiarity with RARPN. OBJECTIVE To demonstrate RARPN technique and outcomes. DESIGN, SETTING, AND PARTICIPANTS A retrospective multicenter study of 227 consecutive RARPNs was performed at the Swedish Medical Center, the University of Michigan, and the University of California, Los Angeles, from 2006 to 2013. SURGICAL PROCEDURE RARPN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We assessed positive margins and cancer recurrence. Stepwise regression was used to examine factors associated with complications, estimated blood loss (EBL), warm ischemia time (WIT), operative time (OT), and length of stay (LOS). RESULTS AND LIMITATIONS The median age was 60 yr (interquartile range [IQR]: 52-66), and the median body mass index (BMI) was 28.2 kg/m(2) (IQR: 25.6-32.6). Median maximum tumor diameter was 2.3 cm (IQR: 1.7-3.1). Median OT and WIT were 165 min (IQR: 134-200) and 19 min (IQR: 16-24), respectively; median EBL was 75 ml (IQR: 50-150), and median LOS was 2 d (IQR: 1-3). Twenty-eight subjects (12.3%) experienced complications, three (1.3%) had urine leaks, and three (1.3%) had pseudoaneurysms that required reintervention. There was one conversion to radical nephrectomy and three transfusions. Overall, 143 clear cell carcinomas (62.6%) composed most of the histology with eight positive margins (3.5%) and two recurrences (0.9%) with a median follow-up of 2.7 yr. In adjusted analyses, intersurgeon variation was associated with complications (odds ratio [OR]: 3.66; 95% confidence interval, 1.31-10.27; p = 0.014) and WIT (parameter estimate [PE; plus or minus standard error]: 4.84 ± 2.14; p = 0.025). Higher surgeon volume was associated with shorter WIT (PE: -0.06 ± 0.02; p = 0.002). Higher BMI was associated with longer OT (PE: 2.09 ± 0.56; p < 0.001). Longer OT was associated with longer LOS (PE: 0.01 ± 0.01; p = 0.002). Finally, there was a trend for intersurgeon variation in OT (PE: 18.5 ± 10.3; p = 0.075). CONCLUSIONS RARPN has acceptable morbidity and oncologic outcomes, despite intersurgeon variation in WIT and complications. Greater experience is associated with shorter WIT. PATIENT SUMMARY Robot-assisted retroperitoneoscopic partial nephrectomy has acceptable morbidity and oncologic outcomes, and there is intersurgeon variation in warm ischemia time and complications.

Expectant management for men with early stage prostate cancer.

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Risk of second primary malignancies among cancer survivors in the United States, 1992 through 2008.

In the current study, the authors attempted to describe the incidence, most common sites, and mortality of second primary malignancies among survivors of common cancers.

Initial experience with electronic tracking of specific tumor sites in men undergoing active surveillance of prostate cancer

OBJECTIVES Targeted biopsy, using magnetic resonance (MR)-ultrasound (US) fusion, may allow tracking of specific cancer sites in the prostate. We aimed to evaluate the initial use of the technique to follow tumor sites in men on active surveillance of prostate cancer. METHODS AND MATERIALS A total of 53 men with prostate cancer (all T1c category) underwent rebiopsy of 74 positive biopsy sites, which were tracked and targeted using the Artemis MR-US fusion device (Eigen, Grass Valley, CA) from March 2010 through January 2013. The initial biopsy included 12 cores from a standard template (mapped by software) and directed biopsies from regions of interest seen on MR imaging (MRI). In the repeat biopsy, samples were taken from sites containing cancer at the initial biopsy. Outcomes of interest at second MR-US biopsy included (a) presence of any cancer and (b) presence of clinically significant cancer. RESULTS All cancers on initial biopsy had either Gleason score 3+3 = 6 (n = 63) or 3+4 = 7 (n = 11). At initial biopsy, 23 cancers were within an MRI target, and 51 were found on systematic biopsy. Cancer detection rate on repeat biopsy (29/74, 39%) was independent of Gleason score on initial biopsy (P = not significant) but directly related to initial cancer core length (P<0.02). Repeat sampling of cancerous sites within MRI targets was more likely to show cancer than resampling of tumorous systematic sites (61% vs. 29%, P = 0.005). When initial cancer core length was≥4 mm within an MRI target, more than 80% (5/6) of follow-up tracking biopsies were positive. An increase of Gleason score was uncommon (9/74, 12%). CONCLUSIONS Monitoring of specific prostate cancer-containing sites may be achieved in some men using an electronic tracking system. The chances of finding tumor on repeat specific-site sampling was directly related to the length of tumor in the initial biopsy core and presence of tumor within an MRI target; upgrading of Gleason score was uncommon. Further research is required to evaluate the potential utility of site-specific biopsy tracking for patients with prostate cancer on active surveillance.

Surgeon Characteristics and Long-Term Trends in the Adoption of Laparoscopic Radical Nephrectomy

PURPOSE We describe longitudinal trends in surgeon adoption of laparoscopic radical nephrectomy. We assessed whether this technique is associated with specific surgeon and/or practice setting characteristics. METHODS AND MATERIALS We used Surveillance, Epidemiology and End Results-Medicare data to identify patients who underwent laparoscopic or open radical nephrectomy for early stage kidney cancer from 1995 through 2005. We assessed long-term trends in surgeon adoption of laparoscopic radical nephrectomy and fit multilevel logistic regression models to estimate the association between surgeon or practice setting characteristics and patient receipt of laparoscopic radical nephrectomy. RESULTS The annual proportion of patients receiving laparoscopic radical nephrectomy increased from 1.4% in 1995 to 44.9% in 2005 (p <0.001). In patients treated by recent medical school graduates (graduation year 1991 or thereafter) the likelihood of undergoing laparoscopic radical nephrectomy was more than 2-fold higher when urologists practiced at National Cancer Institute designated Cancer Centers (OR 2.37, 95% CI 1.11-5.06) or in urban settings (OR 2.92, 95% CI 1.10-7.75). Patients treated by urologists who graduated before 1991 and had a major academic affiliation (OR 1.78, 95% CI 1.34-2.38) or were in a group practice (OR 1.99, 95% CI 1.51-2.63) were significantly more likely to be treated with a minimally invasive surgical approach than those treated in nonacademic and solo practices, respectively. CONCLUSIONS Urologist adoption of laparoscopic radical nephrectomy increased progressively from 1995 through 2005 and was influenced by urologist proximity to training, academic affiliation and rural/urban status. These data clarify residual barriers to surgeon adoption of laparoscopic radical nephrectomy and potentially of other innovative surgical therapies.

Improvement in Clinical TNM Staging Documentation Within a Prostate Cancer Quality Improvement Collaborative

OBJECTIVE To assess the effectiveness of a feedback and educational intervention to increase documentation of clinical tumor-node-metastasis (TNM) stage among urologists in a statewide quality improvement collaborative. METHODS The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a consortium of urology practices that aims to improve the quality and cost-efficiency of prostate cancer care. In pilot data collection activities, trained abstractors recorded medical record documentation of clinical TNM stage by participating urologists. We compared levels of TNM stage documentation in 12 MUSIC practices at baseline and after performance feedback and a collaborative-wide educational intervention. We examined patient and practice characteristics associated with documentation of TNM stage. RESULTS We accrued 491 and 581 men with newly diagnosed prostate cancer during the baseline and postfeedback phases of data collection, respectively. At baseline, 58% of patients had clinical TNM staging in the medical record, ranging from 19% to 96% across 12 practices (P <.05). After the intervention, documentation improved to 79% of patients overall, with 7 individual practices achieving significant improvements (all P <.05). The greatest improvements in documentation occurred among patients treated in smaller practices (ie, 1-4 urologists). CONCLUSION After collaborative review of staging criteria and feedback of baseline performance, urologists in MUSIC practices dramatically improved documentation of clinical TNM stage. This finding underscores the behavioral change possible with the collaborative quality improvement model and ensures the necessary risk stratification data for our ongoing efforts to improve care.

Trends in Medical Management of Men With Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia

OBJECTIVE To examine trends in medical management of men with benign prostatic hyperplasia/lower urinary tract symptoms (BPH/LUTS) in relation to sentinel events specific to particular medication regimens. METHODS Using the National Ambulatory Medical Care Survey (1993-2010), we identified outpatient visits by men with BPH/LUTS. We ascertained prescriptions for medical therapy and distinguished between treatment with alpha-blocker monotherapy, 5α reductase inhibitor monotherapy, combination therapy, and anticholinergic therapy. We evaluated temporal trends in prescription patterns and assessed for changes after sentinel events related to each regimen (eg, Food and Drug Administration [FDA] approval for tamsulosin and alpha-blocker monotherapy). Finally, we used multivariable logistic regression to determine factors associated with each treatment strategy. RESULTS From 1993 to 2010, there were over 101 million outpatient visits for men with a diagnosis of BPH/LUTS. Among these visits, the use of BPH medication increased from 14% of visits in 1993-1995 to over 40% of visits in 2008-2010 (P <.001). After tamsulosin was FDA approved, providers were twice as likely to prescribe ABs (odds ratio 2.35; 95% confidence interval 1.60-3.43). Providers were 5 times as likely to prescribe combination therapy after level 1 evidence supported its use (odds ratio 5.13; 95% confidence interval 3.35-7.86). CONCLUSION Over the last 15 years, there has been a steady increase in the use of medications to manage men with BPH. Providers seem to have readily adopted novel medications and treatment regimens in response to FDA approval and supportive level 1 evidence.

Contemporary, age-based trends in the incidence and management of patients with early-stage kidney cancer☆

PURPOSE Although kidney cancer incidence and nephrectomy rates have risen in tandem, clinical advances have generated new uncertainty regarding the optimal management of patients with small renal tumors, especially the elderly. To clarify existing practice patterns, we assessed contemporary trends in the incidence and management of patients with early-stage kidney cancer. MATERIALS AND METHODS Using Surveillance, Epidemiology, and End Results data, we identified adult patients diagnosed with T1aN0M0 kidney cancer from 2000 to 2010. We determined age-adjusted and age-specific incidence and management rates (i.e., nonoperative, ablation, partial nephrectomy [PN], and radical nephrectomy) per 100,000 adults and determined the average annual percent change (AAPC). Finally, we compared management groups using multinomial logistic regression accounting for patient characteristics, cancer information, and county-level measures for health. RESULTS From 2000 to 2010, we identified 41,645 adults diagnosed with T1aN0M0 kidney cancer. Overall incidence increased from 3.7 to 7.0 per 100,000 adults (AAPC = 7.0%, P<0.001). Over the study interval, rates of PN (AAPC = 13.1%, P<0.001) increased substantially, becoming the most used treatment by 2010. Among the elderly, rates of nonoperative management and ablation approached nephrectomy rates for those aged 75 to 84 years and became the predominant strategy for patients older than 84 years. Adjusting for clinical, oncological, and environmental factors, older patients less frequently underwent PN and more often received ablative or nonoperative management (P<0.001). CONCLUSIONS As the incidence of early-stage kidney cancer rises, patients are increasingly treated with nonoperative and nephron-sparing strategies, especially among the most elderly. The broader array of treatment options suggests opportunities to better personalize kidney cancer care for seniors.