Dattatraya Patil

Multicenter Evaluation of the Prostate Health Index to Detect Aggressive Prostate Cancer in Biopsy Naïve Men

PURPOSE We evaluated the ability of PHI to discriminate aggressive prostate cancer from indolent or no cancer in a biopsy naïve population. MATERIALS AND METHODS Two independent prospective cohorts of 561 and 395 subjects, respectively, with no prior prostate biopsy who were enrolled at different clinical sites were used to validate the results. We compared the diagnostic specificity of PHI to prebiopsy total and percent free prostate specific antigen using prostate biopsy results. We also determined the optimal PHI threshold to discriminate aggressive prostate cancer (Gleason score 7 or greater) from indolent or no prostate cancer (Gleason score 6 or less). RESULTS In the primary cohort higher PHI values were significantly associated with Gleason score 7 or greater. The AUC to detect aggressive prostate cancer was 0.815. At 95% sensitivity PHI specificity was 36.0% vs 17.2% and 19.4% for total and percent free prostate specific antigen, respectively. At 95% sensitivity for detecting aggressive prostate cancer the optimal PHI cutoff was 24, which would help avoid 41% of unnecessary biopsies. A cutoff of 24 led to 36% biopsies avoided with few aggressive cancers missed. These results were confirmed in the validation cohort. CONCLUSIONS The PHI detected aggressive prostate cancer with better specificity than total and percent free prostate specific antigen in a biopsy naïve population. It could be a useful tool to decrease unnecessary prostate biopsies.

Patient Frailty and Discharge Disposition following Radical Cystectomy

Background Patients with bladder cancer who are treated with cystectomy are at high risk for complications and prolonged length of stay. This population tends to be of advanced age with underlying comorbidities, and thus more likely to have decreased physiologic reserve (ie, frailty). Our objective was to evaluate the relationship between frailty and discharge disposition for patients with bladder cancer treated with cystectomy. Materials and Methods Using data from the National Surgical Quality Improvement Program, we identified patients with bladder cancer undergoing cystectomy (2011‐2014). Our exposure of interest was frailty, based on the 11‐point modified Frailty Index (mFI). Patients were deemed robust (mFI = 0), pre‐frail (mFI = 0.09‐0.18), or frail (mFI ≥ 0.27). Our outcome of interest was discharge disposition defined as home, skilled nursing facility, and rehabilitation dichotomized as home versus non‐home for multivariable logistic regression analysis. We then generated predicted probabilities of non‐home discharge based on frailty and in‐hospital complications. Results Among 4330 patients treated with radical cystectomy, 32.8% were robust, 65.1% were pre‐frail, and 2.2% were frail. Overall, 86.2% were discharged home, 4.4% to a rehabilitation facility, and 9.4% to a skilled nursing facility. Frail patients were more likely to be discharged to non‐home care (vs. robust, odds ratio, 2.33; 95% confidence interval, 1.34‐4.03), which was independent of whether they experienced a major complication prior to discharge. Conclusion Frailty is a significant predictor of non‐home discharge following radical cystectomy. This finding was independent of inpatient complications. These data will assist providers in setting patient expectations and have important implications for allocating postoperative resources. Micro‐Abstract Among 4330 patients undergoing radical cystectomy in the National Surgical Quality Improvement Program from 2011 through 2014, frail patients, as determined by the modified Frailty Index, were more likely to be discharged to a location other than home (odds ratio, 2.33; 95% confidence interval, 1.34‐4.03). Predicting non‐home discharge may assist providers in setting expectations and allocating postoperative resources.

Relief of Urinary Symptom Burden after Primary Prostate Cancer Treatment

Purpose: Harms of prostate cancer treatment on urinary health related quality of life have been thoroughly studied. In this study we evaluated not only the harms but also the potential benefits of prostate cancer treatment in relieving the pretreatment urinary symptom burden. Materials and Methods: In American (1,021) and Spanish (539) multicenter prospective cohorts of men with localized prostate cancer we evaluated the effects of radical prostatectomy, external radiotherapy or brachytherapy in relieving pretreatment urinary symptoms and in inducing urinary symptoms de novo, measured by changes in urinary medication use and patient reported urinary bother. Results: Urinary symptom burden improved in 23% and worsened in 28% of subjects after prostate cancer treatment in the American cohort. Urinary medication use rates before treatment and 2 years after treatment were 15% and 6% with radical prostatectomy, 22% and 26% with external radiotherapy, and 19% and 46% with brachytherapy, respectively. Pretreatment urinary medication use (OR 1.4, 95% CI 1.0–2.0, p = 0.04) and pretreatment moderate lower urinary tract symptoms (OR 2.8, 95% CI 2.2–3.6) predicted prostate cancer treatment associated relief of baseline urinary symptom burden. Subjects with pretreatment lower urinary tract symptoms who underwent radical prostatectomy experienced the greatest relief of pretreatment symptoms (OR 4.3, 95% CI 3.0–6.1), despite the development of deleterious de novo urinary incontinence in some men. The magnitude of pretreatment urinary symptom burden and beneficial effect of cancer treatment on those symptoms were verified in the Spanish cohort. Conclusions: Men with pretreatment lower urinary tract symptoms may experience benefit rather than harm in overall urinary outcome from primary prostate cancer treatment. Practitioners should consider the full spectrum of urinary symptom burden evident before prostate cancer treatment in treatment decisions.

Onodera's Prognostic Nutritional Index as an Independent Prognostic Factor in Clear Cell Renal Cell Carcinoma

OBJECTIVE To evaluate the relationship between the Onodera Prognostic Nutritional Index (OPNI) and overall survival, as well as recurrence-free survival, in clear cell renal cell carcinoma (ccRCC) patients following nephrectomy. MATERIALS AND METHODS Three hundred forty-one patients who underwent nephrectomy for ccRCC were analyzed. The optimum OPNI cutoff score of 44.7 was determined by receiver operating characteristic analysis and patients were placed in either the low or high OPNI group, with OPNI values of ≤44.7 and ≥44.8, respectively. Kaplan-Meier analysis was performed to evaluate the univariate impact of the OPNI groups on overall survival and recurrence-free survival. OPNIs association with overall survival and recurrence-free survival, with adjustments for other patient and tumor qualities, was assessed with univariate and multivariate Cox regression analysis. RESULTS Median (95% CI) overall survival times for the low and high OPNI groups were 21.1 months and 37.9 months, respectively. OPNI was determined to be an independent prognostic factor in multivariate analysis, and after controlling for patient and tumor characteristics, the low OPNI group experienced a 1.67-fold (hazard ratio: 1.67, 95% confidence interval: 1.05-2.68) increased risk of overall mortality. CONCLUSION Preoperative OPNI is a valuable independent prognostic indicator of overall survival and recurrence-free survival in patients with ccRCC following nephrectomy.

Urologist Use of Cystoscopy for Patients Presenting With Hematuria in the United States

OBJECTIVE To evaluate the prevalence of cystoscopy and factors associated with use among hematuria patients presenting to urologists, based on results from a nationally representative survey. METHODS Using the National Ambulatory Medical Care Survey (2006-2012), we identified outpatient visits to urologists for hematuria, and excluded visits associated with benign diagnoses (eg, urinary tract infection). Our primary outcome was performed or planned cystoscopy. We hypothesized that major risk factors (ie, gross hematuria, tobacco use, age >50, male gender) would be associated with increased cystoscopy use. We used multivariable logistic regression to evaluate the relationship between available patient, provider, and practice setting factors and use of cystoscopy. RESULTS Among an estimated 10.8 million hematuria visits to urologists, cystoscopy was planned or performed after 34.7% of visits (95% confidence interval [CI] 30.7-39.0). Patients with gross hematuria (adjusted odds ratio 2.17, 95% CI 1.28-3.69) and current tobacco users (adjusted odds ratio 2.48, 95% CI 1.40-4.39) had over twice the odds of undergoing cystoscopy compared to patients without those risk factors. We estimated that there are over 20,000 missed cancer cases annually among moderate- and high-risk hematuria patients, and nearly 230,000 excess cystoscopy cases annually for patients with near-zero cancer risk. CONCLUSION Despite guidelines emphasizing the importance of cystoscopy in hematuria evaluations, just over one-third of patients diagnosed with hematuria by urologists undergo this procedure. There also appears to be considerable misallocation of cystoscopy for hematuria patients, with excessive use among low-risk patients and significant potential for missed cancer cases among those at higher risk of malignancy.

Elevated preoperative neutrophil-to-lymphocyte ratio may be associated with decreased overall survival in patients with metastatic clear cell renal cell carcinoma undergoing cytoreductive nephrectomy

Objective Inflammatory serum markers have proven to be a powerful predictive tool of patient prognosis in cancer treatment for a wide variety of solid organ malignancies, predominantly in the context of localized disease. In this study we evaluated the preoperative neutrophil-to-lymphocyte ratio (NLR) as a predictive tool in patients with metastatic clear cell renal cell carcinoma (RCC). Methods Sixty-four patients with metastatic clear cell RCC undergoing nephrectomy were selected. Only patients with preoperative NLR were included for survival analysis. Patients were categorized into high and low NLR score determined by plotting the NLR ROC curve. Multivariable analysis was performed. Results Median age was 60.8 years (38.2–81.2). Median follow-up time was 8.1 months (0.1–106.3). Fuhrman grade distribution was: 2 (3.1%) grade 1, 6 (9.4%) grade 2, 24 (37.5%) grade 3 and 32 (50.0%) grade 4. Median NLR score was 3.5 (1.4–31.0). NLR ≥ 4 was associated with decreased overall survival compared to NLR < 4 (p = 0.017). Multivariable survival analysis showed NLR ≥ 4 as an independent predictor of survival (Hazard ratio (HR) 2.41, 95%CI 1.05–5.50, p = 0.03). Conclusion Elevated preoperative NLR is associated with poor prognosis in patients with metastatic kidney cancer. Preoperative NLR is a useful tool, which can predict prognosis, stratify patients for postoperative surveillance, and help guide decisions for therapy.

Physical activity profiles of overweight and obese women in rural Georgia.

Physical Activity Profiles of Overweight and Obese Women in Rural Georgia The value of moderate and vigorous physical activity (PA) is wellknown and substantiated by a large body of research.1 In addition, research on the value of light activity and the negative effect of sedentary behavior is starting to accumulate.2,3 However, little is known about PA in relation to time spent sedentary and the frequency and length of interruptions in sedentary behavior in overweight and obese patients of safety-net primary care practices such as federally qualified health centers (FQHCs). This study investigated the PA profiles of overweight and obese women, focusing on light activity and breaks in sedentary behavior.

Circulating microRNAs in plasma as potential biomarkers for the early detection of prostate cancer

MicroRNAs (miRNAs) have been linked to prostate cancer (PC) risk; however, their role as a screening biomarker for PC has yet to be determined. We examined whether circulating miRNAs in plasma could be potential biomarkers for the early detection of PC among men undergoing prostate needle biopsy.

Treatment of men with high-risk prostate cancer based on race, insurance coverage, and access to advanced technology

PURPOSE We characterized factors related to nondefinitive management (NDM) of patients with high-risk prostate cancer and assessed impact from race, insurance status, and facility-level volume of technologically advanced prostate cancer treatments (i.e., intensity-modulated radiation therapy, robotic-assisted laparoscopic radical prostatectomy) on this outcome. METHODS We identified men with high-risk localized prostate cancer (based on D׳Amico criteria) in the National Cancer Database (2010-2012). Primary outcome was NDM (i.e., delayed/no treatment with prostatectomy/radiation therapy or androgen-deprivation monotherapy). Treating facilities were classified by quartiles of proportions of patients treated with advanced technology. Multivariable regression estimated odds of primary outcome based on race, insurance status, and facility-level technology use, and evaluated for interactions between these covariates. RESULTS Among 60,300 patients, 9,265 (15.4%) received NDM. This was more common among non-White men (P<0.001), Medicaid/uninsured patients (P<0.001), and those managed at facilities in the lowest quartile of technology use (25.1% vs. 11.0% highest, P<0.001). Though NDM was common among non-White men with Medicaid/no insurance treated at low-technology centers (43% vs. 10% White, private/Medicare, high-tech facility; adjusted odds ratios = 7.18, P<0.001), this was less likely if this group was managed at a high-tech hospital (22% vs. 43% low-tech, P<0.001). CONCLUSIONS Technology use at a facility correlates with high-quality prostate cancer care and is associated with diminished disparities based on insurance status and patient race. More research is required to characterize other facility-level factors explaining these findings.

Detection of prostate cancer-specific transcripts in extracellular vesicles isolated from post-DRE urine

Background: The measurement of gene expression in post‐digital rectal examination (DRE) urine specimens provides a non‐invasive method to determine a patients risk of prostate cancer. Many currently available assays use whole urine or cell pellets for the analysis of prostate cancer‐associated genes, although the use of extracellular vesicles (EVs) has also recently been of interest. We investigated the expression of prostate‐, kidney‐, and bladder‐specific transcripts and known prostate cancer biomarkers in urine EVs.