Elizabeth Walker-Corkery

Outcomes of Localized Prostate Cancer Following Conservative Management

CONTEXT Most newly diagnosed prostate cancers are clinically localized, and major treatment options include surgery, radiation, or conservative management. Although conservative management can be a reasonable choice, there is little contemporary prostate-specific antigen (PSA)-era data on outcomes with this approach. OBJECTIVE To evaluate the outcomes of clinically localized prostate cancer managed without initial attempted curative therapy in the PSA era. DESIGN, SETTING, AND PARTICIPANTS A population-based cohort study of men aged 65 years or older when they were diagnosed (1992-2002) with stage T1 or T2 prostate cancer and whose cases were managed without surgery or radiation for 6 months after diagnosis. Living in areas covered by the Surveillance, Epidemiology, and End Results (SEER) program, the men were followed up for a median of 8.3 years (through December 31, 2007). Competing risk analyses were performed to assess outcomes. MAIN OUTCOME MEASURES Ten-year overall survival, cancer-specific survival, and major cancer related interventions. RESULTS Among men who were a median age of 78 years at cancer diagnosis, 10-year prostate cancer-specific mortality was 8.3% (95% confidence interval [CI], 4.2%-12.8%) for men with well-differentiated tumors; 9.1% (95% CI, 8.3%-10.1%) for those with moderately differentiated tumors, and 25.6% (95% CI, 23.7%-28.3%) for those with poorly differentiated tumors. The corresponding 10-year risks of dying of competing causes were 59.8% (95% CI, 53.2%-67.8%), 57.2% (95% CI, 52.6%-63.9%), and 56.5% (95% CI, 53.6%-58.8%), respectively. Ten-year disease-specific mortality for men aged 66 to 74 years diagnosed with moderately differentiated disease was 60% to 74% lower than earlier studies: 6% (95% CI, 4%-8%) in the contemporary PSA era (1992-2002) compared with results of previous studies (15%-23%) in earlier eras (1949-1992). Improved survival was also observed in poorly differentiated disease. The use of chemotherapy (1.6%) or major interventions for spinal cord compression (0.9%) was uncommon. CONCLUSIONS Results following conservative management of clinically localized prostate cancer diagnosed from 1992 through 2002 are better than outcomes among patients diagnosed in the 1970s and 1980s. This may be due, in part, to additional lead time, overdiagnosis related to PSA testing, grade migration, or advances in medical care.

Benign Prostatic Hyperplasia Specific Health Status Measures in Clinical Research: How Much Change in the American Urological Association Symptom Index and the Benign Prostatic Hyperplasia Impact Index is Perceptible to Patients?

PURPOSE We assessed the relationship between changes in scores for the American Urological Association (AUA) symptom index and benign prostatic hyperplasia (BPH) impact index with patient global ratings of improvement in a large Veterans Affairs trial comparing different pharmacological therapies for BPH. MATERIALS AND METHODS The primary analyses compared absolute score changes from baseline with global ratings of improvement at 13 weeks for 1,218 men. RESULTS Subjects who rated themselves as being slightly improved had a mean decrease in AUA symptom index and BPH impact index scores of 3.1 and 0.4 points, respectively. However, the baseline scores strongly influenced this relationship. CONCLUSIONS These data provide guidance for investigators using the AUA symptom index and BPH impact index as outcome measures.

Natural experiment examining impact of aggressive screening and treatment on prostate cancer mortality in two fixed cohorts from Seattle area and Connecticut

Abstract Objective:To determine whether the more intensive screening and treatment for prostate cancer in the Seattle-Puget Sound area in 1987-90 led to lower mortality from prostate cancer than in Connecticut. Design: Natural experiment comparing two fixed cohorts from 1987 to 1997. Setting: Seattle-Puget Sound and Connecticut surveillance, epidemiology, and end results areas. Participants: Population based cohorts of male Medicare beneficiaries aged 65-79 drawn from the Seattle (n=94 900) and Connecticut (n=120 621) areas. Main outcome measures: Rates of screening for prostate cancer, treatment with radical prostatectomy and external beam radiotherapy, and prostate cancer specific mortality. Results: The prostate specific antigen testing rate in Seattle was 5.39 (95% confidence interval 4.76 to 6.11) times that of Connecticut, and the prostate biopsy rate was 2.20 (1.81 to 2.68) times that of Connecticut during 1987-90. The 10 year cumulative incidences of radical prostatectomy and external beam radiotherapy up to 1996 were 2.7% and 3.9% for Seattle cohort members compared with 0.5% and 3.1% for Connecticut cohort members. The adjusted rate ratio of prostate cancer mortality up to 1997 was 1.03 (0.95 to 1.11) in Seattle compared with Connecticut. Conclusion: More intensive screening for prostate cancer and treatment with radical prostatectomy and external beam radiotherapy among Medicare beneficiaries in the Seattle area than in the Connecticut area was not associated with lower prostate cancer specific mortality over 11 years of follow up.

Transurethral resection of the prostate among medicare beneficiaries : 1984 to 1997

Purpose: We examine the epidemiology and associated risks of transurethral resection of the prostate among Medicare beneficiaries for the period 1984 to 1997.Materials and Methods: We used hospital claims for transurethral resection of the prostate from a 20% national sample of Medicare beneficiaries for the period 1991 to 1997. Risk of mortality and reoperation were evaluated using life table methods and compared to those for the period 1984 to 1990. We also examined the association between surgical volume and adverse outcomes following resection using unique urologist identifier codes from the 1997 part B Medicare claims.Results: Compared to 1984 to 1990, age adjusted rates of transurethral resection for benign prostatic hyperplasia (BPH) during 1991 to 1997 declined by approximately 50% for white (14.6 to 6.72/1,000) and 40% for black (11.8 to 6.58/1,000) men. Of the men who underwent resection for BPH during the recent period 53% were 75 years old or older but 30-day mortality in men 70 years old or o...

Using Repeated Measures of Symptom Score, Uroflowmetry and Prostate Specific Antigen in the Clinical Management of Prostate Disease

Measurements of American Urological Association symptom score, peak urine flow rate and prostate specific antigen (PSA) are often followed over time in urological management. However, their interpretation is confounded by within-patient variability due to chance. Data from 2 clinical trials are used to examine the magnitude of this variation. When these measures are repeated at a short interval variation is modest and might easily be misinterpreted as a true change in patient condition. For example, approximately 20% of patients might be expected to have a chance increase or decrease in symptom score by at least 4.9 points, in peak urine flow rate by at least 4.1 ml. per second or in PSA by at least 1.6 ng./ml. Clinicians can use these data to help interpret repeated measures of these variables in patients, and can consider obtaining paired measurements to decrease the effect of chance variation when they plan on following them over time.

The rising prevalence of androgen deprivation among older American men since the advent of prostate‐specific antigen testing: a population‐based cohort study

To investigate the effect of efforts in the early detection of prostate cancer using prostate‐specific antigen (PSA) testing in the USA, by estimating the regional prevalence of androgen deprivation therapy (ADT) among older men in 1993–2000, and correlating the prevalence with early detection and aggressive treatment rates in 1987–91, as some authors predicted that ADT, a treatment traditionally reserved for advanced prostate cancer, would become less common over time as a result of such efforts.

Augmenting advance care planning in poor prognosis cancer with a video decision aid: a preintervention-postintervention study.

The authors tested whether an educational video on the goals of care in advanced cancer (life‐prolonging care, basic care, or comfort care) helped patients understand these goals and had an impact on their preferences for resuscitation.

Augmenting advance care planning in poor prognosis cancer with a video decision aid

The authors tested whether an educational video on the goals of care in advanced cancer (life‐prolonging care, basic care, or comfort care) helped patients understand these goals and had an impact on their preferences for resuscitation.

Randomized, Controlled Trial of an Advance Care Planning Video Decision Support Tool for Patients With Advanced Heart Failure

Background: Conversations about goals of care and cardiopulmonary resuscitation (CPR)/intubation for patients with advanced heart failure can be difficult. This study examined the impact of a video decision support tool and patient checklist on advance care planning for patients with heart failure. Methods: This was a multisite, randomized, controlled trial of a video-assisted intervention and advance care planning checklist versus a verbal description in 246 patients ≥64 years of age with heart failure and an estimated likelihood of death of >50% within 2 years. Intervention participants received a verbal description for goals of care (life-prolonging care, limited care, and comfort care) and CPR/intubation plus a 6-minute video depicting the 3 levels of care, CPR/intubation, and an advance care planning checklist. Control subjects received only the verbal description. The primary analysis compared the proportion of patients preferring comfort care between study arms immediately after the intervention. Secondary outcomes were CPR/intubation preferences and knowledge (6-item test; range, 0–6) after intervention. Results: In the intervention group, 27 (22%) chose life-prolonging care, 31 (25%) chose limited care, 63 (51%) selected comfort care, and 2 (2%) were uncertain. In the control group, 50 (41%) chose life-prolonging care, 27 (22%) selected limited care, 37 (30%) chose comfort care, and 8 (7%) were uncertain (P<0.001). Intervention participants (compared with control subjects) were more likely to forgo CPR (68% versus 35%; P<0.001) and intubation (77% versus 48%; P<0.001) and had higher mean knowledge scores (4.1 versus 3.0; P<0.001). Conclusions: Patients with heart failure who viewed a video were more informed, more likely to select a focus on comfort, and less likely to desire CPR/intubation compared with patients receiving verbal information only. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01589120.

Measurement of overall and disease-specific health status: does the order of questionnaires make a difference?

Objectives: This study was designed to detect any effect of order when modules on disease-specific and overall health status are combined in an outcomes research questionnaire. Methods: Men with symptomatic benign prostatic hyperplasia (BPH) were prospectively enrolled in a clinical trial of an educational intervention in Group Health Cooperative of Puget Sound, a prepaid group practice. Within the trial, 392 consecutive men were randomized to one of two versions of a baseline questionnaire. One had a 38-item module on BPH-specific health status first, followed by a 30-item module on overall health status; the other had the modules in reverse order. Scores were compared for three BPH-specific scales and eight scales measuring overall health. Data were collected in the form of self-administered questionnaires. Results: Comparing the groups assigned the two versions of the questionnaire, no significant differences in scores on any of the health status scales were found. Conclusions: In this dataset, we could find no evidence of an order effect when modules on BPH-specific and overall health status were combined in different sequences.