Daniel Lee

Repeat Prostate Biopsy and the Incremental Risk of Clinically Insignificant Prostate Cancer

OBJECTIVES To determine the incremental risk of diagnosis of clinically insignificant prostate cancer with serial prostate biopsies. METHODS We reviewed our institutional radical prostatectomy (RP) database comprising 2411 consecutive patients undergoing RP. We then stratified patients by the prostate biopsy on which their cancer was diagnosed and correlated biopsy number with the risk of clinically insignificant disease and adverse pathology at radical prostatectomy. RESULTS A total of 1867 (77.4%), 281 (11.9%), and 175 (7.3%) patients underwent 1, 2, and 3 or more prostate biopsies, respectively, before RP. Increasing number of prostate biopsies was associated with increasing prostate volume (P <.01), prostate-specific antigen (P <.01), associated prostate intraepithelial neoplasia (P <.01), and increased likelihood of clinical Gleason 6 or less disease (P <.01). On pathologic analysis, increasing number of prostate biopsies was associated with increased risk of low-volume (P <.01), organ-confined (P <.01) disease. The risk of clinically insignificant disease was found to be 31.1%, 43.8%, and 46.8% in those undergoing 1, 2, and 3+ prostate biopsies, respectively. Conversely, the risk of adverse pathology was found to be 64.6%, 53.0%, and 52.0% in those undergoing 1, 2, and 3+ prostate biopsies, respectively. CONCLUSIONS Patients undergoing multiple prostate biopsies before RP are more likely to harbor clinically insignificant prostate cancer than those who only undergo 1 biopsy before resection. Nonetheless, the risk of adverse pathology in patients undergoing serial biopsies remains significant. The increased risk of prostate cancer overdiagnosis and overtreatment must be balanced with the continued risk of clinically significant disease when counseling patients regarding serial biopsies.

Conduit Urinary Diversion

This review summarizes the salient aspects of the ileal conduit with 3 pedagogical objectives in mind: (1) to describe the surgical steps emphasizing important surgical principles, (2) to provide insight on various preoperative and postoperative considerations, and (3) to summarize the risks of the long-term complications and quality of life. We aim to inform a broad medical readership.

MP92-08 RACIAL DISPARITY AND ADHERENCE TO QUALITY MEASURES FOR RADIATION THERAPY OF PROSTATE CANCER

NOTES pathway. Precipitating events for these deviations were recorded by abstractors. RESULTS: A total of 4710 RPs were performed by 209 surgeons in 41 participating MUSIC practices. Thirty day readmission rates were 4.1% overall, 3.8% for those with LOS 0-2 days and 7.1% for those with LOS 3 days. The most frequent events driving readmission were gastrointestinal (GI) events such as ileus or bowel injury (24.5%), infection (19.8%), urine leaks (13.0%) and pulmonary embolism (PE)/ deep vein thrombosis (DVT) (12.5%) (Table 1). GI events resulted in 56.3% of readmissions within 3 days of discharge (Figure 1). Infection, urine leaks and PE/DVT remained persistent drivers beyond this period (Figure 1). CONCLUSIONS: GI and urine complications represent the majority of drivers resulting in 30 day readmission. Measures to specifically reduce these by appropriate patient education and close postdischarge surveillance may represent a high impact opportunity for quality improvement efforts after RP.

PD06-08 DISPARITY IN MINORITY REPRESENTATION WITHIN MEDICARE ACCOUNTABLE CARE ORGANIZATIONS

METHODS: We engaged 25 men in semi-structured telephone interviews focusing on their initial experience transitioning from IMPACT to ACA-based insurance coverage. Interviews were recorded and transcribed for review. Transcripts were coded for themes around patient experience with IMPACT, the insurance enrollment process, and initial experience with comprehensive health insurance. RESULTS: Demographic and quality of life are summarized in Table 1. Four thematic domains were identified: 1) insurance enrollment process, 2) attributes and challenges of care in IMPACT, 3) attributes and challenges of care with ACA-based insurance, and 4) overall changes in care after insurance enrollment. Major findings are presented in Table 2. Twenty-three men enrolled in Medicaid. Fifteen men reported completing a paper application with 24% of patients receiving help from social workers and 20% from family members. Insurance coverage began more than 3 months after completing the application 40% of the time. Ten men reported that navigating CaP treatment was easier with IMPACT. Twelve patients reported improved access to care with insurance, while 6 patients reported increased health care costs and 5 reporting decreased health care costs after insurance enrollment. 24% of patients were able to keep the same primary doctor and urologist after enrollment. CONCLUSIONS: Low-income men gaining insurance coverage under the ACA are predominantly enrolling in Medicaid. They face delays in coverage and interruptions in continuity of care, but report improved access. The relative burden of healthcare costs after gaining insurance is mixed.

New developments in the management of nonmuscle invasive bladder cancer

Purpose of review In this review, we summarize the core principles in the management of nonmuscle invasive bladder cancer (NMIBC) with an emphasis on new developments that have emerged over the last year. Recent findings NMIBC has a propensity to recur and progress. Risk stratification has facilitated appropriate patient selection for treatment but improved tools, including biomarkers, are still needed. Enhanced cystoscopy with photodynamic imaging and narrow band imaging show promise for diagnosis, risk stratification, and disease monitoring and has been formally recommended this year by the American Urological Association. Attempts at better treatment, especially in refractory high-risk cases, include the addition of intravesical hyperthermia, combination and sequential therapy with existing agents, and the use of novel agents such as mycobacterial cell wall extract. New data are emerging regarding the potential role of early cystectomy in bacillus Calmette–Guerin-refractory NMIBC patients. Summary NMIBC represents an assortment of disease states and continues to pose management challenges. Continued research is needed to bolster the evidence needed for patients and providers to make data-driven treatment decisions.