Gregory Mills

The Association between Mortality and Distance to Treatment Facility in Patients with Muscle Invasive Bladder Cancer

Purpose: Regionalization of bladder cancer treatment is suggested to improve quality of care. As an unintended consequence some patients travel farther for care with unknown implications on outcomes. We characterized the relationship between distance and overall mortality in patients with invasive bladder cancer and those who underwent radical cystectomy. Materials and Methods: We performed a retrospective cohort study using NCDB (National Cancer Database) from 2004 to 2012 to identify patients with muscle invasive bladder cancer (cT2a‐T4 N0 M0). We also extracted a subgroup of patients who underwent radical cystectomy. Multivariate Cox proportional hazards and multinomial logistic regression analyses were performed in each group, controlling for demographic, clinical, hospital and geographic factors. Results: For 34,729 patients with muscle invasive bladder cancer traveling farther for treatment was associated with a lower probability of overall mortality (referent less than 12.5 miles, 12.5 to 49.9 miles HR 0.96, 95% CI 0.92–0.99 and 50 to 249.9 miles HR 0.91, 95% CI 0.86–0.96). This was significant for patients with cT2 disease and those treated at academic centers (p ≤0.05). For 11,059 patients who underwent radical cystectomy this trend did not reach significance. However, longer distance was associated with surgery at a high volume institution and receipt of neoadjuvant chemotherapy (each p <0.001). Conclusions: Patients who traveled farther for bladder cancer treatment did not experience inferior survival outcomes and traveling to academic institutions was associated with reduced mortality. For patients who undergo cystectomy this relationship was equivocal, although longer distance was associated with receiving neoadjuvant chemotherapy or surgery at a high volume facility. These findings may reflect a complex association of regionalization of bladder cancer care with patient individual health and health care seeking behavior.

MP92-18 A STUDY OF UROLOGY RESIDENT SLEEP PATTERNS IN RELATION TO VOLUME AND CATEGORY OF OVERNIGHT PAGES IN A HOME CALL SYSTEM

RESULTS: Minimization of healthcare waste, use of high value care, and standardization of clinical processes scored the highest on importance and impact, while panelists felt that quality measurement tools (i.e., patient satisfaction measures, Physician Quality Reporting System) were less important to teach and unlikely to substantially improve patient care. Expert panelists clearly distinguish quality measurement (i.e. reporting systems) and quality improvement activities (Table). CONCLUSIONS: These results broadly support a QI curriculum focused on methods to eliminate waste, standardize care pathways, and strengthen processes of urologic patient care. Educating residents about quality measurement and reporting may not meaningfully improve patient outcomes. Future research will assess methods to improve resident engagement in QI education.

PD58-12 PSA SCREENING AT THE INTERSECTION OF POLITICS AND POLICY

METHODS: Statistical significance implies that an observed event is unlikely to occur by chance alone. The fragility index is defined as the minimum number of patients in an arm of a trial whose status would have to change from “non-event” to “event” in order to turn a statistically significant result into a non-significant one. All RCTs published in the 4 major urology journals between 2011-2015 were identified. We excluded studies not reporting dichotomous outcomes, as well as those with non-significant results and non-parallel designs. We applied the Fisher exact test to determine fragility index values. RESULTS: 332 RCTs were identified, and 42 studies met inclusion criteria. Median sample size (IQR) was 99 (65, 179), while median event rate per study outcome was 38 (24, 65). The median fragility index was 3 (1, 4.5), indicating that an addition of only three alternate events to an arm of the average trial would have eliminated its statistical significance. There was statistically significant correlation between the fragility index and events per study (r1⁄40.552, p1⁄40.01) as well as sample size (r1⁄40.493, p1⁄40.01). CONCLUSIONS: Statistically significant results in urology RCTs areoften fragile,withsignificancehingingon fewevents.This isofparticular concern in studies that may have large loss to follow-up numbers. Urologists should therefore interpret RCTs cautiously. There may be a role for reporting fragility index values routinely alongside the p-value to provide additional guidance as to the statistical robustness of findings.

PD32-05 PROSTATE CANCER SCREENING: EFFECT OF EARLY MEDICAID EXPANSION

INTRODUCTION AND OBJECTIVES: The Affordable Care Act of 2010 transformed medical insurance and healthcare access for Americans. A significant component of the ACA, was expansion of Medicaid eligibility for low income individuals. Five states (CA, CT, MN, NJ, WA) & DC expanded Medicaid eligibility prior to the ACA mandate. The effect that improved coverage had on the prevalence of prostate specific antigen (PSA) screening is unknown. METHODS: We compared the rate of self-reported PSA as a function of state Medicaid early expansion (MEE) vs. non-expansion (NE). Data from the 2012 and 2014 Behavioral Risk Factor Surveillance System was used to identify asymptomatic men (aged 40-64) without prostate cancer who reported PSA testing in the past 12 months. Age, race, income, education, insurance, marital status, smoking, access to healthcare provider (HCP), and HCP0s recommendation to have PSA test were extracted. Income categories were stratified by relationship to federal poverty level (FPL): <138% FPL; 138-400% FPL; >400% FPL. Multivariate logistic regression models were used to evaluate the odds of and rate of change in PSA screening among MEE and NE states. RESULTS: Among 158,103 survey respondents, the prevalence of PSA screening decreased between 2012 and 2014 (OR 0.87, p<0.001), rates were similar in MEE and NE states (OR 1.02, p1⁄40.8). The decrease was smallest in low-income populations <138% FPL than in higher income populations (OR 0.92, p1⁄40.27; OR 0.88, p1⁄40.002; and OR 0.85, p<0.001 respectively). Men <138% FPL were more likely to undergo PSA screening if living in a MEE than NE state (OR 1.6, p1⁄40.04). In this population of men <138% FPL in MEE states, there was an increase in PSA screening (Figure 1), especially if they were Hispanic or Non-Hispanic black (NHB) males (OR 1.53 and 1.62 respectively, both p<0.001). Though access to HCP and insurance status were lowest among those <138% FPL, these variables did not significantly affect the prevalence of PSA screening. CONCLUSIONS: Regardless of income or expansion of access, self-reported PSA screening declined between 2011 and 2013. This may be in part due to the 2012 United States Preventive Services Task Force recommendation against PSA-based screening. However, Medicaid expansion decreased the disparity between PSA baseline screening rates for low-income populations, particularly among Hispanic and NHB males.

MP76-05 RADICAL CYSTECTOMY: THE ASSOCIATION BETWEEN DISTANCE TO TREATING FACILITY AND QUALITY OF CARE

INTRODUCTION AND OBJECTIVES: Overall Survival for Muscle Invasive Bladder Cancer (MIBC) with Radical Cystectomy (RC) is improved with neoadjuvant chemotherapy and surgery in high-volume centers. However, concentration of care inadvertently increases the average travel distance for patients who may have a post-RC complication. Using data from the National Cancer Data Base (NCDB), we evaluated the association between increasing travel distance in patients undergoing RC and the likelihood of receiving high volume care, neoadjuvant chemotherapy and overall survival. METHODS: Data were obtained from NCDB 2004-13. Patients had MIBC (T2-T4a, N0, M0) treated with RC. Distance to treating facility was examined in 3 categories (<12.5, 12.5-49, 50-250 miles). Multivariate logistic regression analysis was preformed to examine the interaction between distance and overall survival, then to test receipt of neoadjuvant chemotherapy. Multinomial regression examined the interaction between travel distance and RC volume tertiles (<3, 3-6, >6 per year). RESULTS: 11,059 patients treated with RC identified, including 2609 that had neoadjuvant chemotherapy. Hazard ratios for overall survival, receipt of neoadjuvant chemotherapy, as well as volume of RC are presented in Table 1. Overall survival was not associated with travel distance. As distance to facility increased, so did the likelihood that a patient received neoadjuvant chemotherapy. Increase in distance was also associated with facilities that had high volumes of RC. CONCLUSIONS: As distance to treatment facility increased, the likelihood that a patient would receive neoadjuvant chemotherapy or have surgery at a high volume center also increased, supporting the relationship between concentration of care and quality. Nevertheless, overall survival was not affected by distance. Source of Funding: None

MP02-18 TRENDS IN MINIMALLY INVASIVE SIMPLE PROSTATECTOMY FOR BENIGN PROSTATIC ENLARGEMENT IN THE UNITED STATES

INTRODUCTION AND OBJECTIVES: Benign prostatic obstruction (BPO) is the main cause of lower urinary tract symptoms (LUTS) in men over 50 years of age. This condition is highly prevalent and many men will undergo medical or surgical treatment leading to ejaculatory dysfunction with a potential negative impact on quality of life (QoL). Through urological generations, patients were warned of the almost inevitable risk of ejaculatory dysfunction as consequence of the treatment without asking their opinion on this issue. Our objective was to evaluate with a survey the patient’s wishes on ejaculatory function after surgical treatment for BPO. METHODS: All consecutive patients with LUTS and sexually active scheduled for BPO relief surgery in a tertiary reference center were included in this prospective evaluation. All patients were offered a surgical treatment with preservation of the ejaculatory function and were informed of the risk of failure and early recurrence of LUTS with the need of medication or surgery. Once information given, patients were asked their wish about the preservation of ejaculatory function. RESULTS: A total of 489 patients were included with a mean age of 68.3 years [43.2 93.8]. Among them, 175 (36%) preferred to undergo a surgery with attempt to preserve the ejaculatory function. The mean age of this group (group 1) was 61.8 [43.2 81.2] compared to 71.9 [52.8 93.8] for the group preferring a complete BPO relief surgery (group 2), p<0.001. At the preoperative evaluation, the mean IPSS symptom score was significantly lower in group 1 compared to group 2 (18.3 [1 35] versus 21 [3 35], p1⁄40.02). Regarding the IPSS QoL score, there was no difference between the two groups, 5.7 [0 6] in group 1 versus 4.45 [1 5] in group 2, p1⁄40.2. No difference in Qmax was observed: 9.3 mL/s [1 31] in group 1 versus 7.77 mL/s [2 26] in group 2, p1⁄40.45. There was also no difference in prostate volume performed with transrectal ultrasound, 57.5 mL [17 220] in group 1 versus 62.3 mL [15 164] in group 2, p1⁄40.13. About medication, 41% were under alpha-blockers in group 1 versus 51% in group 2 (p1⁄40.06), and 9% were under 5-ARI in group 1 versus 24% in group 2, p<0.001. CONCLUSIONS: This survey showed that more than one third of patients with indication of surgical treatment for BPO would like to preserve antegrade ejaculation despite of the risk of failure and early recurrence of LUTS. These patients were slightly younger than the others. This issue should be taken into consideration in the decision of the urologists which may change their surgical approach to preserve this function.

MP05-20 ADJUVANT RADIATION REFERRAL PATTERNS IN MEN WITH HIGH-RISK PROSTATE CANCER

Effient (1,) All patients received 4 fiducial markers placed under Transrectal ultrasound guidance (TRUS.) EMLA Cream and lidocaine gel were used to numb the perineum and rectum. 2 needles each double loaded with 2 gold fiducial markers with a spacer in between were placed transperineally into the prostate. 2 fiducial markers were placed at the right and left base and 2 fiducial markers were placed at the right and left apex. Patients had a CT scan after procedure to confirm ideal geometry of the marker placement. The needles were withdrawn as was the ultrasound transducer. Gentle pressure was applied by the nursing staff. All patients were monitored for bleeding afterwards by a registered nurse. RESULTS: All 23 patients who were on anticoagulation and underwent fiducial marker placement were discharged home the same day of the procedure. No patient experienced significant bleeding in the peri-procedural window and no patient had any untoward cardiovascular event. CONCLUSIONS: This series suggests active anticoagulation is not an absolute contraindication to fiducial marker placement in patients undergoing SBRT or IGRT for prostate cancer. Transperineal fiducial marker placement appears to be safe in patients on active anticoagulation medication. These patients should be closely monitored after the procedure for bleeding complications.

MP04-20 THE ASSOCIATION BETWEEN MORTALITY AND DISTANCE TO TREATMENT FACILITY IN PATIENTS WITH INVASIVE BLADDER CANCER

CYFRA 21-1 (CYFRA) in these patients compared with classic tumor markers. METHODS: Serum levels of CYFRA and other classic tumor markers: CA19-9, SCC, and C-reactive protein (CRP) were measured in 66 patients with T1G3 (n 1⁄4 20) or muscle invasive bladder cancer (n 1⁄4 46) without metastasis between Jan 2011 and Aug 2015. Cut-off values of the tumor markers were determined by receiver operating characteristic analyses. Prognostic values of age, gender, T stage, hydronephrosis, albumin, hemoglobin, CA19-9, SCC, CRP, and CYFRA were evaluated using multivariate analysis with a Cox proportional hazards model. RESULTS: The median (range) value of CYFRA was 2.6 (1.134) ng/mL. The median follow-up period was 24.3 (1.1-58.1) months. Prognostic values of age (< 73 vs. 73), T stage (< T2 vs. T2), hydronephrosis (absence vs. presence), albumin (cut-off 4.0 g/dL, median), hemoglobin (cut-off 12.7 g/dL, median), CA19-9 (cut-off 21 U/mL), SCC (cut-off 1.5 ng/mL), CRP (cut-off 0.1mg/dL), andCYFRA (cut-off 3.5 ng/mL) were evaluated dichotomously. Multivariate analyses revealed that CYFRA (p 1⁄4 0.017) was the only significant and independent predictor of cancer-specific survival. Risk of cancer-specific mortality was 4.48-fold (95%CI, 1.37-18.27; p1⁄4 0.012) higher in CYFRA-high patients than in CYFRA-low/either classic tumor marker-high patients. Figure. Cancer-specific survival curves according to CYFRA and classic tumor markers status. CONCLUSIONS: The current results indicated that cancerspecific mortality of non-metastatic bladder cancer could be better predicted by CYFRA than other previously reported tumor markers. Further prospective analyses will be needed to confirm our results.