Fang Zhu

Clinicopathological outcomes after radical cystectomy for clinical T2 urothelial carcinoma: further evidence to support the use of neoadjuvant chemotherapy

Study Type – Therapy (case series)
Level of Evidence 4

The effect of gender on response to bacillus Calmette-Guérin therapy for patients with non-muscle-invasive urothelial carcinoma of the bladder.

Study Type – Therapy (case series)
Level of Evidence 4

Trends in regionalization of radical cystectomy in three large northeastern states from 1996 to 2009

OBJECTIVES To assess regionalization trends and short-term clinical outcomes in patients undergoing radical cystectomy for urothelial carcinoma. MATERIALS AND METHODS Using 1996-2009 discharge data from New York (NY), New Jersey (NJ) and Pennsylvania (PA), all patients ≥ 18 years with urothelial carcinoma undergoing cystectomy were identified using ICD-9 coding. We assigned hospital volume status by quintiles based on relative proportions of cystectomies performed on a per hospital basis in 1996; very low volume hospitals: 0-2 (VLVH), low: 3-4 (LVH), moderate: 5-8 (MVH), high: 9-31 (HVH), and very high: ≥ 32 (VHVH). Changes in the proportion of procedures performed by volume categories were assessed over time, and patient characteristics were compared between groups. RESULTS A total of 14,404 patients met inclusion criteria. For each year increase from 1996 to 2009, the odds of having surgery performed at a VHVH increased by 22% (odds ratio [OR] 1.22, confidence interval [CI] 1.04-1.44). Patients undergoing surgery at a VHVH were less likely to be African American (OR 0.59 [CI 0.39-0.91]), or insured through Medicaid (OR 0.65 [CI 0.50-0.84]) or Medicare (OR 0.84 [CI 0.75-0.94]). Controlling for year treated, total procedures performed, and patient characteristics, median hospital length of stay (HLOS) was shorter (median difference -0.89 days [CI -1.12 to -0.66]), and patients were significantly less likely to die during their hospital stay if treated at a VHVH compared with a VLVH (OR 0.33 [CI 0.22-0.49]). CONCLUSIONS There has been extensive regionalization of cystectomy to VHVHs in NY, NJ, and PA since 1996. Despite apparent improvements in mortality and HLOS in patients treated at higher volume centers in our sample, future investigations more rigorously adjusting for hospital structural characteristics and patient severity are necessary to confirm these findings. Disparities in access to VHVH care are still evident and must be addressed.

Clinical characteristics associated with treatment type for localized renal tumors: implications for practice pattern assessment.

OBJECTIVE To determine the associations between the pretreatment characteristics and treatment selection in patients presenting with clinical stage I renal masses. MATERIALS AND METHODS Using institutional data, patients presenting with clinical stage I (≤ 7 cm) renal tumors that were managed with active surveillance (AS), tumor ablation (ABL), partial nephrectomy (PN), or radical nephrectomy (RN) from 2005 to 2011 were identified. The associations between the pretreatment characteristics and the selected treatment strategy were assessed using multinomial regression models, with RN as the reference group. RESULTS A total of 969 patients (mean age 61.9 ± 12.8 years) with 1034 clinical stage I lesions (mean tumor size 3.3 ± 1.5 cm) met the inclusion criteria. The patients were initially treated with RN (29.4%), PN (38.8%), ABL (6.1%), and AS (25.7%). Traditionally captured covariates, including older age (PN, odds ratio [OR] 0.96, 95% confidence interval [CI] 0.94-0.99]) and decreasing tumor size (PN, OR 0.2, 95% CI 0.1-0.4; ABL, OR 0.01, 95% CI 0.0-0.1; AS, OR 0.2, 95% CI 0.1-0.3) were associated with alternative treatment types compared with RN. However, the characteristics associated with treatment type that are not included in traditional registry or administrative data included the presence of a solitary kidney (PN, OR 11.9, 95% CI 2.9-48.9; ABL, OR 15.5, 95% CI 2.5-98.1; AS, OR 7.1, 95% CI 1.3-39.3) and high complexity nephrectomy score (PN, OR 0.1, 95% CI 0.1-0.3; ABL, OR 0.1, 95% CI 0.0-0.6; AS, OR 0.1, 95% CI 0.03-0.3). CONCLUSION Pretreatment characteristics associated with treatment type in our series, including the presence of a solitary kidney and anatomic complexity, are poorly captured using administrative and registry data. Observational studies investigating the variations in practice patterns for stage I renal masses require improved integration of clinical and tumor characteristics to reduce selection biases.

Assessing the Clinical Role of Genetic Markers of Early-Onset Prostate Cancer among High-Risk Men Enrolled in Prostate Cancer Early Detection

Background: Men with familial prostate cancer and African American men are at risk for developing prostate cancer at younger ages. Genetic markers predicting early-onset prostate cancer may provide clinically useful information to guide screening strategies for high-risk men. We evaluated clinical information from six polymorphisms associated with early-onset prostate cancer in a longitudinal cohort of high-risk men enrolled in prostate cancer early detection with significant African American participation. Methods: Eligibility criteria include ages 35 to 69 with a family history of prostate cancer or African American race. Participants undergo screening and biopsy per study criteria. Six markers associated with early-onset prostate cancer [rs2171492 (7q32), rs6983561 (8q24), rs10993994 (10q11), rs4430796 (17q12), rs1799950 (17q21), and rs266849 (19q13)] were genotyped. Cox models were used to evaluate time to prostate cancer diagnosis and prostate-specific antigen (PSA) prediction for prostate cancer by genotype. Harrells concordance index was used to evaluate predictive accuracy for prostate cancer by PSA and genetic markers. Results: Four hundred and sixty participants with complete data and ≥1 follow-up visit were included. Fifty-six percent were African American. Among African American men, rs6983561 genotype was significantly associated with earlier time to prostate cancer diagnosis (P = 0.005) and influenced prediction for prostate cancer by the PSA (P < 0.001). When combined with PSA, rs6983561 improved predictive accuracy for prostate cancer compared with PSA alone among African American men (PSA = 0.57 vs. PSA + rs6983561 = 0.75, P = 0.03). Conclusions: Early-onset marker rs6983561 adds potentially useful clinical information for African American men undergoing prostate cancer risk assessment. Further study is warranted to validate these findings. Impact: Genetic markers of early-onset prostate cancer have potential to refine and personalize prostate cancer early detection for high-risk men. Cancer Epidemiol Biomarkers Prev; 21(1); 53–60. ©2011 AACR.

442 REGIONALIZATION OF RADICAL CYSTECTOMY: TRENDS BY HOSPITAL VOLUME 1996–2009 USING STATE DISCHARGE DATA

INTRODUCTION AND OBJECTIVES: Centralization of complex urologic oncology procedures to high volume centers has been proposed as a means of improving surgical quality of care. We hypothesized that performance of radical cystectomy has become increasingly regionalized to very high volume hospitals resulting in improved short term clinical and mortality outcomes. METHODS: Using 1996 to 2009 hospital discharge data from NY, NJ, and PA provided by Databay Resources, all patients 18 years with transitional cell carcinoma undergoing cystectomy were identified using ICD-9 coding. We assigned hospital volume status by quintiles based on relative proportions of radical cystectomies performed on a per hospital basis in 1996; very low volume hospital: 0–2 (VLVH), low: 3–4 (LVH), moderate: 5–8 (MVH), high: 9–31 (HVH) and very high: 32 (VHVH). Changes in the relative proportion of procedures performed by hospital volume status were assessed over time, and patient characteristics were compared between groups. Outcome variables including discharge status, inpatient mortality, and hospital length of stay (HLOS) were examined by hospital volume status using logistic regression models. RESULTS: 14,404 patients undergoing cystectomy were included for analysis. From 1996 to 2009, there was a significant shift towards regionalization of care to VHVHs (21 to 38%, p 0.02) and away from VLVHs (20 to 9%, p 0.001). For each year increase (1996–2009), the odds of having surgery performed at a VHVH increased by 16% (OR 1.16 [CI 1.03, 1.31]). Stratified by hospital volume status, there were significant differences between groups in patient age (p 0.0001), race (p 0.0001), gender (p 0.0001), geographic location (p 0.0001), and payer group (p 0.0001). Independent of year treated, patients undergoing surgery at a VHVH were less likely to be African American (OR 0.50 [CI 0.32–0.79]) or insured through Medicaid (OR 0.67 [CI 0.47–0.95]) or Medicare (OR 0.84 [CI 0.76–0.95]). Controlling for year treated, median LOS was shorter (median difference 1.1 days [CI 1.12 to 1.06]) and patients were less likely to die during their hospital stay if treated at a VHVH compared to a VLVH (OR 0.30 [CI 0.17–0.52]). CONCLUSIONS: Since 1996, these data demonstrate that there has been extensive centralization of radical cystectomy to VHVHs, which has resulted in significant reductions in inpatient mortality rates and HLOS over time. Nevertheless, insurer and racial disparities preclude optimal access to care and these discrepancies must still be addressed.