Deepansh Dalela

The Impact of Local Treatment on Overall Survival in Patients with Metastatic Prostate Cancer on Diagnosis: A National Cancer Data Base Analysis.

BACKGROUND The role of local treatment (LT) in patients with metastatic prostate cancer (mPCa) at diagnosis is controversial. OBJECTIVE We set to evaluate the potential impact of LT on overall mortality (OM) in men with mPCa, and how this impact is influenced by tumor and patient characteristics. DESIGN, SETTINGS, AND PARTICIPANTS A total of 15 501 patients with mPCa were identified in the National Cancer Data Base (2004-2012) and categorized in LT (radical prostatectomy or radiation therapy targeted to prostate) versus nonlocal treatment (NLT; all other patients). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The two arms (LT vs NLT) were matched using propensity scores to minimize selection bias. To evaluate LT impact on OM in relation to baseline characteristics, first multivariable Cox regression analysis was used to predict OM in patients treated with NLT, then interaction between predicted OM risk and LT status was tested. RESULTS AND LIMITATIONS Overall, 9.5% (n=1470) of patients received LT. In the postpropensity matched cohorts, 3-yr OM-free survival was higher in the LT group versus the NLT group (69% vs 54%; p<0.001). In multivariable Cox regression, the NLT group, age, and Charlson comorbidity index were predictors of OM (all p≤0.03). This model was used to predict the 3-yr OM risk. The interaction between predicted OM and LT status was significant (p<0.001). The benefit of LT on OM decreased progressively as predicted OM risk increased. Specifically, the 3-yr absolute improvement in OM-free survival was 15.7%, for patients with predicted OM risk ≤20% versus 0% for those with predicted OM risk ≥72%. CONCLUSIONS Men with mPCa at diagnosis benefit from LT in terms of OM. This is largely affected by baseline characteristics. Specifically, patients with a relatively low tumor risk and good general health status appear to benefit the most. PATIENT SUMMARY We used a large hospital-based database to evaluate which patients might benefit from local therapy when metastasized prostate cancer was present at diagnosis. Local therapy is associated with a survival benefit in men with less aggressive tumors and good general health.

Measuring to Improve: Peer and Crowd-sourced Assessments of Technical Skill with Robot-assisted Radical Prostatectomy

UNLABELLED Because surgical skill may be a key determinant of patient outcomes, there is growing interest in skill assessment. In the Michigan Urological Surgery Improvement Collaborative (MUSIC), we assessed whether peer and crowd-sourced (ie, layperson) video review of robot-assisted radical prostatectomy (RARP) could distinguish technical skill among practicing surgeons. A total of 76 video clips from 12 MUSIC surgeons consisted of one of four parts of RARP and underwent blinded review by MUSIC peer surgeons and prequalified crowd-sourced reviewers. Videos were rated for global skill (Global Evaluation Assessment of Robotic Skills) and procedure-specific skill (Robotic Anastomosis and Competency Evaluation). We fit linear mixed-effects models to estimate mean peer and crowd ratings for each video. Individual video ratings were aggregated to calculate surgeon skill scores. Peers (n=25) completed 351 video ratings over 15 d, whereas crowd-sourced reviewers (n=680) completed 2990 video ratings in 38 h. Surgeon global skill scores ranged from 15.8 to 21.7 (peer) and from 19.2 to 20.9 (crowd). Peer and crowd ratings demonstrated strong correlation for both global (r=0.78) and anastomosis (r=0.74) skills. The two groups consistently agreed on the rank order of lower scoring surgeons, suggesting a potential role for crowd-sourced methodology in the assessment of surgical performance. Lack of patient outcomes is a limitation and forms the basis of future study. PATIENT SUMMARY We demonstrated the large-scale feasibility of assessing the technical skill of robotic surgeons and found that online crowd-sourced reviewers agreed with experts on the rank order of surgeons with the lowest technical skill scores.

Cancer-Specific Mortality of Asian Americans Diagnosed With Cancer: A Nationwide Population-Based Assessment

BACKGROUND Racial disparities in cancer survival outcomes have been primarily attributed to underlying biologic mechanisms and the quality of cancer care received. Because prior literature shows little difference exists in the socioeconomic status of non-Hispanic whites and Asian Americans, any difference in cancer survival is less likely to be attributable to inequalities of care. We sought to examine differences in cancer-specific survival between whites and Asian Americans. METHODS The Surveillance, Epidemiology, and End Results Program was used to identify patients with lung (n = 130 852 [16.9%]), breast (n = 313 977 [40.4%]), prostate (n = 166 529 [21.4%]), or colorectal (n = 165 140 [21.3%]) cancer (the three leading causes of cancer-related mortality within each sex) diagnosed between 1991 and 2007. Fine and Grays competing risks regression compared the cancer-specific mortality (CSM) of eight Asian American groups (Chinese, Filipino, Hawaiian/Pacific Islander, Japanese, Korean, other Asian, South Asian [Indian/Pakistani], and Vietnamese) to non-Hispanic white patients. All P values were two-sided. RESULTS In competing risks regression, the receipt of definitive treatment was an independent predictor of CSM (hazard ratio [HR] = 0.37, 95% confidence interval [CI] = 0.35 to 0.40; HR = 0.55, 95% CI = 0.53 to 0.58; HR = 0.61, 95% CI = 0.60 to 0.62; and HR = 0.27, 95% CI = 0.25 to 0.29) for prostate, breast, lung, and colorectal cancers respectively, all P < .001). In adjusted analyses, most Asian subgroups (except Hawaiians and Koreans) had lower CSM relative to white patients, with hazard ratios ranging from 0.54 (95% CI = 0.38 to 0.78) to 0.88 (95% CI = 0.84 to 0.93) for Japanese patients with prostate and Chinese patients with lung cancer, respectively. CONCLUSIONS Despite adjustment for potential confounders, including the receipt of definitive treatment and tumor characteristics, most Asian subgroups had better CSM than non-Hispanic white patients. These findings suggest that underlying genetic/biological differences, along with potential cultural variations, may impact survival in Asian American cancer patients.

Impact of smoking on perioperative outcomes after major surgery

BACKGROUND To investigate the impact of smoking on perioperative outcomes in patients undergoing one of the 16 major cardiovascular, orthopedic, or oncologic surgical procedures. METHODS We relied on the American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2011). Procedure-specific multivariable logistic regression models assessed the association between smoking status (non, former, or current smokers) and risk of 30-day morbidity and mortality. RESULTS Overall, 141,802 patients were identified. A total of 12.5%, 14.6%, and 14.9% of non, former, and current smokers, respectively, experienced at least one complication (P < .001). In multivariable models, current smokers had higher odds of overall, pulmonary, wound, and septic/shock complications following most cardiovascular and oncologic surgeries compared with nonsmokers. The odds of experiencing such adverse outcomes were significantly lower in former smokers compared with current smokers, but still higher compared with nonsmokers. CONCLUSIONS The effect of smoking on perioperative outcomes is procedure dependent. Current and, even though mitigated, former smoking negatively influence outcomes following cardiovascular or oncologic procedures. Patients undergoing major procedures should be encouraged to discontinue tobacco smoking to achieve optimal procedural outcomes.

Causes of hospital readmissions after urologic cancer surgery

OBJECTIVES The Hospital Readmissions Reduction Program mandates reimbursement reductions to hospitals with higher than expected rates of readmissions. We examine causes and predictors of readmissions following major procedures in urologic oncology. MATERIALS AND METHODS Using the American College of Surgeons National Surgical Quality Improvement Program database, patients undergoing radical prostatectomy (RP), radical (RN) or partial nephrectomy (PN), and radical cystectomy (RC) during the year 2012 were abstracted. Rates of unplanned readmission within 30 days after surgery, as well as causes of readmission, were identified. Multivariable logistic regression models were fitted to examine the association between patient perioperative factors and odds of readmission. RESULTS Overall, we observed a 5.5% unplanned 30-day readmission rate. Readmission rates for patients treated with RP, RN, PN, and RC were 4.1%, 5.2%, 4.5%, and 15.9%, respectively. For each procedure, approximately two-third of readmissions occurred within the first 10 days following hospital discharge. Commonest causes of readmission after RP included thromboembolic (13.6%), wound (12.2%), renal/genitourinary (12.2%), and gastrointestinal (11.8%); after RN, wound (12.9%) and gastrointestinal (12.9%); after PN, renal/genitourinary (19.6%), cardiovascular (9.8%), and bleeding/hematoma (9.8%); and after RC, renal/genitourinary (15.5%), wound (14.8%), and sepsis/infection (14.1%). RC was significantly associated with readmission. Patients undergoing open RP or PN were more likely to be readmitted relative to their minimally invasive counterparts (odds ratio = 1.53, 95% CI: 1.12-2.08, P = 0.007 and odds ratio = 2.51, 95% CI: 1.38-4.55, P = 0.003, respectively). CONCLUSIONS Readmissions are relatively common following major urologic oncology procedures. Compared with RP, RN, or PN, RC patients experience the highest burden of readmission. Venous thromboembolism is a common modifiable cause of readmission following urologic cancer surgery. Minimally invasive approach is associated with decreased odds of readmission following RP and PN.

Genomic Classifier Augments the Role of Pathological Features in Identifying Optimal Candidates for Adjuvant Radiation Therapy in Patients With Prostate Cancer: Development and Internal Validation of a Multivariable Prognostic Model

Purpose Despite documented oncologic benefit, use of postoperative adjuvant radiotherapy (aRT) in patients with prostate cancer is still limited in the United States. We aimed to develop and internally validate a risk-stratification tool incorporating the Decipher score, along with routinely available clinicopathologic features, to identify patients who would benefit the most from aRT. Patient and Methods Our cohort included 512 patients with prostate cancer treated with radical prostatectomy at one of four US academic centers between 1990 and 2010. All patients had ≥ pT3a disease, positive surgical margins, and/or pathologic lymph node invasion. Multivariable Cox regression analysis tested the relationship between available predictors (including Decipher score) and clinical recurrence (CR), which were then used to develop a novel risk-stratification tool. Our study adhered to the Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis guidelines for development of prognostic models. Results Overall, 21.9% of patients received aRT. Median follow-up in censored patients was 8.3 years. The 10-year CR rate was 4.9% vs. 17.4% in patients treated with aRT versus initial observation ( P < .001). Pathologic T3b/T4 stage, Gleason score 8-10, lymph node invasion, and Decipher score > 0.6 were independent predictors of CR (all P < .01). The cumulative number of risk factors was 0, 1, 2, and 3 to 4 in 46.5%, 28.9%, 17.2%, and 7.4% of patients, respectively. aRT was associated with decreased CR rate in patients with two or more risk factors (10-year CR rate 10.1% in aRT v 42.1% in initial observation; P = .012), but not in those with fewer than two risk factors ( P = .18). Conclusion Using the new model to indicate aRT might reduce overtreatment, decrease unnecessary adverse effects, and reduce risk of CR in the subset of patients (approximately 25% of all patients with aggressive pathologic disease in our cohort) who benefit from this therapy.

Temporal trends in receipt of adequate lymphadenectomy in bladder cancer 1988 to 2010

INTRODUCTION AND OBJECTIVE The importance of pelvic lymphadenectomy (LND) for diagnostic and therapeutic purposes at the time of radical cystectomy (RC) for bladder cancer is well documented. Although some debate remains on the optimal number of lymph nodes removed, 10 nodes has been proposed as constituting an adequate LND. We used data from the Surveillance, Epidemiology, and End Results database to examine predictors and temporal trends in the receipt of an adequate LND at the time of RC for bladder cancer. MATERIAL AND METHODS Within the Surveillance, Epidemiology, and End Results database, we extracted data on all patients with nonmetastatic bladder cancer receiving RC in the years 1988 to 2010. First, we assess the proportion of individuals undergoing RC who received an adequate LND (≥10 nodes removed) over time. Second, we calculate odds ratios (ORs) of receiving an adequate LND using logistic regression modeling to compare study periods. Covariates included sex, race, age, region, tumor stage, urban vs. rural location, and insurance status. RESULTS Among the 5,696 individuals receiving RC during the years 1988 to 2010, 2,576 (45.2%) received an adequate LND. Over the study period, the proportion of individuals receiving an adequate LND increased from 26.4% to 61.3%. The odds of receiving an adequate LND increased over the study period; a patient undergoing RC in 2008 to 2010 was over 4-fold more likely to receive an adequate LND relative to a patient treated in 1988 to 1991 (OR = 4.63, 95% CI: 3.32-6.45). In addition to time of surgery, tumor stage had a positive association with receipt of adequate LND (OR = 1.49 for stage IV [T4 N1 or N0] vs. stage I [T1 or Tis], 95% CI: 1.22-1.82). Age, sex, marital status, and race were not significant predictors of adequate LND. CONCLUSION Adequacy of pelvic LND remains an important measure of surgical quality in bladder cancer. Our data show that over the years 1988 to 2010, the likelihood of receiving an adequate LND has increased substantially; however, a substantial minority of patients still does not receive LND. Further study into factors leading to adequate LND is needed to increase the use of this important technique.

A Pragmatic Randomized Controlled Trial Examining the Impact of the Retzius-sparing Approach on Early Urinary Continence Recovery After Robot-assisted Radical Prostatectomy

BACKGROUND Retzius-sparing (posterior) robot-assisted radical prostatectomy (RARP) may expedite postoperative urinary continence recovery. OBJECTIVE To compare the short-term (≤3 mo) urinary continence (UC), urinary function (UF), and UF-related bother outcomes of posterior RARP compared with standard anterior approach RARP. DESIGN, SETTING, AND PARTICIPANTS A total of 120 patients aged 40-75 yr with low-intermediate-risk prostate cancer (per the National Comprehensive Cancer Network guidelines) underwent primary RARP at a tertiary care institution. INTERVENTION Eligible men were randomized to receive either posterior (n=60) or anterior (n=60) RARP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES Primary outcome was UC (defined as 0 pads/one security liner per day) 1 week after catheter removal. Secondary outcomes were short-term (≤3 mo) UC recovery, and UF and UF-related bother scores (measured by the International Prostate Symptom Score [IPSS] and IPSS quality-of-life scores, respectively) assessed at 1 and 2 wk, and 1 and 3 mo following catheter removal. Continence outcomes were objectively verified using 24-hr pad weights. UC recovery was analyzed using Kaplan-Meier method and Cox proportional hazards regression; UF and UF-related bother outcomes were compared using linear generalized estimating equations (GEEs). Perioperative complications, positive surgical margin, and biochemical recurrence-free survival (BCRFS) represent secondary outcomes reported in the study. RESULTS AND LIMITATIONS Compared with 48% in the anterior arm, 71% men undergoing posterior RARP were continent 1 wk after catheter removal (p=0.01); corresponding median 24-h pad weights were 25 and 5g (p=0.001). Median time to continence in posterior versus anterior RARP was 2 and 8 d postcatheter removal, respectively (log-rank p=0.02); results were confirmed on multivariable regression analyses. GEE analyses showed that UF-related bother (but not UF) scores were significantly lower in the posterior versus anterior RARP group at 1 wk, 2 wk, and 1 mo on GEE analyses. Incidence of postoperative complications (12% anterior vs 18% posterior) and probability of BCRFS (0.91 vs 0.91) were comparable in the two arms. CONCLUSIONS In this single-center randomized study, the Retzius-sparing approach of RARP resulted in earlier recovery of UC and lower UF-related bother compared with standard RARP. These results require long-term validation and reproduction by other centers, as well as studies on men with high-risk localized disease. PATIENT SUMMARY In our hands, men with low-intermediate-risk prostate cancer undergoing Retzius-sparing robot-assisted radical prostatectomy (RARP) had earlier recovery of urinary continence and lower urinary function-related bother than those undergoing standard RARP.

Novel biomarkers of acute kidney injury: Evaluation and evidence in urologic surgery

Patients undergoing urologic surgery are at risk of acute kidney injury (AKI) and consequently long-term deterioration in renal function. AKI is further associated with significantly higher odds of perioperative complications, prolonged hospital stay, higher mortality and costs. Therefore, better awareness and detection of AKI, as well as identification of AKI determinants in the urological surgery setting is warranted to pre-empt and mitigate further deterioration of renal function in patients at special risk. New consensus criteria provide precise definitions of diagnosis and description of the severity of AKI. However, they rely on serum creatinine (SCr), which is known to be an inaccurate marker of early changes in renal function. Therefore, several new urinary and serum biomarkers promise to address the gap associated with the use of SCr. Novel biomarkers may complement SCr measurement or most likely improve the diagnostic accuracy of AKI when used in combinations. However, novel biomarkers have to prove their clinical applicability, accuracy, and cost effectiveness prior to implementation into clinical practice. Most preferably, novel biomarkers should help to positively improve a patients long-term renal functional outcomes. The purpose of this review is to discuss currently available biomarkers and to review their clinical evidence within urologic surgery settings.

Asian Americans and prostate cancer: A nationwide population-based analysis

INTRODUCTION It remains largely unknown if there are racial disparities in outcomes of prostate cancer (PCa) for Asian American and Pacific Islanders (PIs) (AAPIs). We examined differences in diagnosis, management, and survival of AAPI ethnic groups, relative to their non-Hispanic White (NHW) counterparts. METHODS Patients (n = 891,100) with PCa diagnosed between 1988 and 2010 within the surveillance, epidemiology, and end results database were extracted and stratified by ethnic group: Chinese, Japanese, Filipino, Hawaiian, Korean, Vietnamese, Asian Indian/Pakistani, PI, and Other Asian. The effect of ethnic group on stage at presentation, rates of definitive treatment, and PCa-specific mortality was assessed. The severity at diagnosis was defined as: localized (TxN0M0), regional (TxN1M0), or metastatic (TxNxM1). RESULTS Relative to NHWs, Asian Indian/Pakistani, Filipino, Hawaiian, and PI men had significantly worse outcomes. Filipino (odds ratio [OR] = 1.38, 95% CI: 1.27-1.51), Hawaiian, (OR = 1.70, 95% CI: 1.41-2.04), Asian Indian/Pakistani (OR = 1.37, 95% CI: 1.15-1.64), and PI men (OR = 1.90, 95% CI: 1.46-2.49) were more likely to present with metastatic PCa (P<0.001). In patients with localized PCa, Filipino men were less likely to receive definitive treatment (OR = 0.91; 95% CI: 0.84-0.97; P = 0.005). Most AAPI groups had lower rates of PCa death except for Hawaiian (hazard ratio = 1.52; 95% CI: 1.30-1.77; P<0.0001) and PI men (hazard ratio = 1.43; 95% CI: 1.12-1.82; P<0.0001). CONCLUSIONS Compared with NHWs, AAPI groups were more likely to present with advanced PCa but had better cancer-specific survival. Conversely, Hawaiian and PI men were at greater risk for PCa-specific mortality. Given the different cancer profiles, our results show that there is a need for disaggregation of AAPI data.