Glen B. Taksler

Explaining racial differences in prostate cancer mortality

In the United States, black males have an annual death rate from prostate cancer that is 2.4 times that of white males. The reasons for this are poorly understood.

Ten-year Outcomes of Sexual Function After Radical Prostatectomy: Results of a Prospective Longitudinal Study

BACKGROUND The long-term impact of radical prostatectomy (RP) on sexual function (SF) and erectile function (EF) has important implications related to the risk-to-benefit ratio of this treatment. OBJECTIVE To determine the long-term effect of RP on male SF and EF over 10 yr of follow-up. DESIGN, SETTING, AND PARTICIPANTS This was a prospective, longitudinal outcomes study in 1836 men following RP at a university hospital. Men were invited to complete the University of California, Los Angeles, Prostate Cancer Index SF survey at baseline, 3, 6, 12, 24, 96, and 120 mo postoperatively and a survey at 4 and 7 yr postoperatively assessing global changes in their EF over the preceding 2 yr. INTERVENTION All men underwent open RP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multiple, generalized linear regression models were used to evaluate the association between time following RP and SF and EF scores controlling for age, prostate-specific antigen, Gleason scores, stage, nerve sparing, race, and marital status. RESULTS AND LIMITATIONS After an expected initial decline, time-dependent improvements in SF and EF were observed through 2 yr postoperatively. Overall, SF and EF were both generally stable between 2 and 10 yr following RP. The subgroups of younger men and men with better preoperative function were more likely to maintain their EF and SF through 10 yr following RP. The primary limitation is the potential bias attributable to nonresponders. CONCLUSIONS The recovery of EF can extend well beyond 2 yr. There is a significant association between younger age and better preoperative function and the likelihood of experiencing improvements beyond 2 yr. Assessing the comparative effectiveness of treatment options for localized prostate cancer must examine SF beyond 2 yr to account for delayed treatment effects and the natural history of SF in the aging male population.

Long-term continence outcomes in men undergoing radical prostatectomy for clinically localized prostate cancer

BACKGROUND Urinary incontinence is a common short-term complication of radical prostatectomy (RP). Little is known about the long-term impact of RP on continence. OBJECTIVE To elucidate the long-term progression of continence after RP. DESIGN, SETTING, AND PARTICIPANTS From October 2000 through September 2012, 1788 men undergoing open RP for clinically localized prostate cancer by a single surgeon at an urban tertiary care center prospectively signed consent to be followed before RP and at 3, 6, 12, 24, 96, and 120 mo after RP. A consecutive sampling method was used and all men were included in this study. INTERVENTION Men underwent open RP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Regression models controlled for preoperative University of California, Los Angeles-Prostate Cancer Index urinary function score (UCLA-PCI-UFS), age, prostate-specific antigen level, Gleason score, stage, nerve-sparing status, race, and marital status were used to evaluate the association of time since RP with two dependent variables: UCLA-PCI-UFS and continence status. RESULTS AND LIMITATION The mean UCLA-PCI-UFS declined between 2 yr and 8 yr (83.8 vs 81.8; p=0.007) and marginally between 8 yr and 10 yr (81.8 vs 79.6; p=0.036) after RP, whereas continence rate did not significantly change during these intervals. Men ≥ 60 yr old experienced a decline in mean UCLA-PCI-UFS between 2 yr and 8 yr (p=0.002) and a marginal decline in continence rate between 2 yr and 10 yr (p=0.047), whereas these variables did not change significantly in men <60 yr old. These outcomes are for an experienced surgeon, so caution should be exercised in generalizing these results. CONCLUSIONS Between 2 yr and 10 yr after RP, there were slight decreases in mean UCLA-PCI-UFS and continence rates in this study. Men aged <60 yr had better long-term outcomes. These results provide realistic long-term continence expectations for men undergoing RP.

National Trends in the Utilization of Partial Nephrectomy Before and After the Establishment of AUA Guidelines for the Management of Renal Masses

OBJECTIVE To assess the impact of the American Urological Association (AUA) guidelines advocating partial nephrectomy for T1 tumors guidelines on the likelihood of undergoing partial nephrectomy. MATERIALS AND METHODS We analyzed the Nationwide Inpatient Sample (NIS), a dataset encompassing 20% of all United States inpatient hospitalizations, from 2007 through 2010. Our dependent variable was receipt of radical vs partial nephrectomy (55.50, 55.51, 55.52, and 55.54 vs 55.4) for a renal mass (International Classification of Disease, 9th Revision [ICD-9] code 189.0). The independent variable of interest was time of surgery (before or after the establishment of AUA guidelines); covariates included a diagnosis of chronic kidney disease (CKD), overall comorbidity, age, race, gender, geographic region, income, and hospital characteristics. Bivariate and multivariable adjusted logistic regression was used to determine the association between receipt of partial nephrectomy and time of guideline establishment. RESULTS We identified 26,165 patients with renal tumors who underwent surgery. Before the guidelines, 4031 patients (27%) underwent partial nephrectomy compared to 3559 (32%) after. On multivariable analysis, undergoing surgery after the establishment of guidelines (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.08-1.32, P <.01) was an independent predictor of partial nephrectomy. Other factors associated with partial nephrectomy were urban location, surgery at a teaching hospital, large hospital bed size, Northeast location, and Black race. Female gender and CKD were not associated with partial nephrectomy. CONCLUSION Although adoption of partial nephrectomy increased after establishment of new guidelines on renal masses, partial nephrectomy remains an underutilized procedure. Future research must focus on barriers to adoption of partial nephrectomy and how to overcome them.

Radical Prostatectomy Improves and Prevents Age Dependent Progression of Lower Urinary Tract Symptoms

PURPOSE The prevalence of lower urinary tract symptoms increases with age and impairs quality of life. Radical prostatectomy has been shown to relieve lower urinary tract symptoms at short-term followup but the long-term effect of radical prostatectomy on lower urinary tract symptoms is unclear. MATERIALS AND METHODS We performed a prospective cohort study of 1,788 men undergoing radical prostatectomy. The progression of scores from the self-administered AUASS (American Urological Association symptom score) preoperatively, and at 3, 6, 12, 24, 48, 60, 84, 96 and 120 months was analyzed using models controlling for preoperative AUASS, age, prostate specific antigen, pathological Gleason score and stage, nerve sparing, race and marital status. This model was also applied to patients stratified by baseline clinically significant (AUASS greater than 7) and insignificant (AUASS 7 or less) lower urinary tract symptoms. RESULTS Men exhibited an immediate worsening of lower urinary tract symptoms that improved between 3 months and 2 years after radical prostatectomy. Overall the difference between mean AUASS at baseline and at 10 years was not statistically or clinically significant. Men with baseline clinically significant lower urinary tract symptoms experienced immediate improvements in lower urinary tract symptoms that lasted until 10 years after radical prostatectomy (13.5 vs 8.81, p <0.001). Men with baseline clinically insignificant lower urinary tract symptoms experienced a statistically significant but clinically insignificant increase in mean AUASS after 10 years (3.09 to 4.94, p <0.001). The percentage of men with clinically significant lower urinary tract symptoms decreased from baseline to 10 years after radical prostatectomy (p = 0.02). CONCLUSIONS Radical prostatectomy is the only treatment for prostate cancer shown to improve and prevent the development of lower urinary tract symptoms at long-term followup. This previously unrecognized long-term benefit argues in favor of the prostate as the primary contributor to male lower urinary tract symptoms.

Clinical and economic outcomes of patients with brain metastases based on symptoms: An argument for routine brain screening of those treated with upfront radiosurgery

Insurers have started to deny reimbursement for routine brain surveillance with magnetic resonance imaging (MRI) after stereotactic radiosurgery (SRS) for brain metastases in favor of symptom‐prompted imaging. The authors investigated the clinical and economic impact of symptomatic versus asymptomatic metastases and related these findings to the use of routine brain surveillance.

Personalized estimates of benefit from preventive care guidelines: a proof of concept.

BACKGROUND The U.S. Preventive Services Task Force (USPSTF) makes recommendations for 60 distinct clinical services, but clinicians rarely have time to fully evaluate and implement the recommendations. OBJECTIVE To complete a proof of concept for prioritization and personalization of USPSTF recommendations, using patient-specific clinical characteristics. DESIGN Mathematical model. DATA SOURCES USPSTF recommendations and supporting evidence and National Vital Statistics Reports. TARGET POPULATION Nonpregnant adults. TIME HORIZON Lifetime. PERSPECTIVE Individual. INTERVENTION USPSTF grade A and B recommendations. OUTCOME MEASURES Personalized gain in life expectancy associated each recommendation. RESULTS OF BASE-CASE ANALYSIS Increases in life expectancy varied more than 100-fold across USPSTF recommendations, and the rank order of benefits varied considerably among patients. For an obese man aged 62 years who smoked and had hypercholesterolemia, hypertension, and a family history of colorectal cancer, the model’s top 3 recommendations (from most to least gain in life expectancy) were tobacco cessation (adding 2.8 life-years), weight loss (adding 1.6 life-years), and blood pressure control (adding 0.8 life-year). Lower-ranked recommendations were a healthier diet, aspirin use, cholesterol reduction, colonoscopy, screening for abdominal aortic aneurysm, and HIV testing (each adding 0.1 to 0.3 life-years). For a person with the same characteristics plus uncontrolled type 2 diabetes mellitus, the model’s top 3 recommendations were diabetes control, tobacco cessation, and weight loss (each adding 1.4 to 1.8 life-years). RESULTS OF SENSITIVITY ANALYSIS Robust to variation of model inputs and satisfied face validity criteria. LIMITATION Expected adherence rates and quality of life were not considered. CONCLUSION Models of personalized preventive care may illustrate how magnitude and rank order of benefit associated with preventive guidelines vary across recommendations and patients. These predictions may help clinicians to prioritize USPSTF recommendations at the patient level.

The Effect of the Diffusion of the Surgical Robot on the Hospital-level Utilization of Partial Nephrectomy.

IntroductionThe rapid diffusion of the surgical robot has been controversial because of the technology’s high costs and its disputed marginal benefit. Some, however, have suggested that adoption of the robot may have improved care for patients with renal malignancy by facilitating partial nephrectomy, an underutilized, technically challenging procedure believed to be less morbid than radical nephrectomy. We sought to determine whether institutional acquisition of the robot was associated with increased utilization of partial nephrectomy. Methods:We used all payer data from 7 states to identify 21,569 nephrectomies. These patient-level records were aggregated to the hospital-level then merged with the American Hospital Association Annual Survey and publicly available data on timing of robot acquisition. We used a multivariable difference-in-difference model to assess at the hospital-level whether robot acquisition was associated with an increase in the proportion of partial nephrectomy, adjusting for hospital nephrectomy volume, year of surgery, and several additional hospital-level factors. Results:In the multivariable-adjusted differences-in-differences model, hospitals acquiring a robot between 2001 and 2004 performed a greater proportion of partial nephrectomy in both 2005 (29.9% increase) and 2008 (34.9% increase). Hospitals acquiring a robot between 2005 and 2008 also demonstrated a greater proportion of partial nephrectomy in 2008 (15.5% increase). In addition, hospital nephrectomy volume and urban location were also significantly associated with increased proportion of partial nephrectomy. Conclusions:Hospital acquisition of the surgical robot is associated with greater proportion of partial nephrectomy, an underutilized, guideline-encouraged procedure. This is one of the few studies to suggest robot acquisition is associated with improvement in quality of patient care.

Calorie labeling and consumer estimation of calories purchased

BackgroundStudies rarely find fewer calories purchased following calorie labeling implementation. However, few studies consider whether estimates of the number of calories purchased improved following calorie labeling legislation.FindingsResearchers surveyed customers and collected purchase receipts at fast food restaurants in the United States cities of Philadelphia (which implemented calorie labeling policies) and Baltimore (a matched comparison city) in December 2009 (pre-implementation) and June 2010 (post-implementation). A difference-in-difference design was used to examine the difference between estimated and actual calories purchased, and the odds of underestimating calories.Participants in both cities, both pre- and post-calorie labeling, tended to underestimate calories purchased, by an average 216–409 calories. Adjusted difference-in-differences in estimated-actual calories were significant for individuals who ordered small meals and those with some college education (accuracy in Philadelphia improved by 78 and 231 calories, respectively, relative to Baltimore, p = 0.03-0.04). However, categorical accuracy was similar; the adjusted odds ratio [AOR] for underestimation by >100 calories was 0.90 (p = 0.48) in difference-in-difference models. Accuracy was most improved for subjects with a BA or higher education (AOR = 0.25, p < 0.001) and for individuals ordering small meals (AOR = 0.54, p = 0.001). Accuracy worsened for females (AOR = 1.38, p < 0.001) and for individuals ordering large meals (AOR = 1.27, p = 0.028).ConclusionsWe concluded that the odds of underestimating calories varied by subgroup, suggesting that at some level, consumers may incorporate labeling information.

Prostate cancer screening practices in a large, integrated health system: 2007–2014

To assess prostate cancer screening practices in primary care since the initial United States Preventive Services Task Force (USPSTF) recommendation against prostate‐specific antigen (PSA) testing for older men, and to assess primary provider variation associated with prostate cancer screening.